Suicidality and Antiepileptic Drugs

Assessing suicide risk in chronic pain management: a narrative review across drug classes

INTRODUCTION

Chronic pain presents a multifaceted challenge in clinical practice, necessitating a nuanced understanding of pharmacological interventions to optimize treatment outcomes. This review provides an outline of various pharmacological agents commonly used in chronic pain management and highlights their safety considerations, particularly regarding suicide risk.

AREAS COVERED

This review discusses the role of antidepressants, anticonvulsants, GABA receptor agonists, NMDA receptor antagonists, corticosteroids, cannabis and cannabinoids, bisphosphonates, calcitonin, and alpha-2 adrenergic receptor agonists in chronic pain management. It assesses their therapeutic benefits, potential for misuse, and psychiatric adverse effects, including the risk of suicide. Each pharmacological class is evaluated in terms of its efficacy, safety profile, and considerations for clinical practice. We searched peer-reviewed English literature on the topic using the MEDLINE database without time restrictions.

EXPERT OPINION

While pharmacological interventions offer promise in alleviating chronic pain, healthcare providers must carefully weigh their benefits against potential risks, including the risk of exacerbating psychiatric symptoms and increasing suicide risk. Individualized treatment approaches, close monitoring, and multidisciplinary collaboration are essential for optimizing pain management strategies while mitigating adverse effects. Ongoing research efforts are crucial for advancing our understanding of these pharmacological interventions and refining pain management practices.

Epilepsy With Suicide: A Bibliometrics Study and Visualization Analysis via CiteSpace

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.

A pharmacovigilance approach for assessing the occurrence of suicide-related events induced by antiepileptic drugs using the Japanese adverse drug event report database

Increased suicidality after antiepileptic drug (AED) treatment remains controversial. This study aimed to investigate the occurrence of suicide-related events (SREs) in Japan. SREs signals with AEDs used orally were evaluated by calculating reporting odds ratios (RORs) and information components (ICs) using the Japanese Adverse Drug Event Report (JADER) database from April 2004 to December 2021. Additionally, factors affecting the occurrence of SREs and time-to-onset from the initial AED treatment were analyzed. Of 22 AEDs, 12 (perampanel hydrate, nitrazepam, levetiracetam, clonazepam, clobazam, sodium valproate, phenobarbital, lamotrigine, lacosamide, gabapentin, zonisamide, and carbamazepine) showed signals of SREs. Patients in their 20 and 30 s, female sex, and concomitant use of multiple AEDs affected the occurrence of SREs. In six AEDs, the median time-to-onset of SREs in patients taking all AEDs was <100 days. The pharmacovigilance approach revealed that several AEDs displayed suicidality signals. Female patients, those in their 20 and 30 s, undergoing combination therapy with ≥2 AEDs, and patients early (<100 days from the initial treatment) in the course of AED therapy should be cautioned about SREs.

Astroglial Connexin43 as a Potential Target for a Mood Stabiliser

Mood disorders remain a major public health concern worldwide. Monoaminergic hypotheses of pathophysiology of bipolar and major depressive disorders have led to the development of monoamine transporter-inhibiting antidepressants for the treatment of major depression and have contributed to the expanded indications of atypical antipsychotics for the treatment of bipolar disorders. In spite of psychopharmacological progress, current pharmacotherapy according to the monoaminergic hypothesis alone is insufficient to improve or prevent mood disorders. Recent approval of esketamine for treatment of treatment-resistant depression has attracted attention in psychopharmacology as a glutamatergic hypothesis of the pathophysiology of mood disorders. On the other hand, in the last decade, accumulated findings regarding the pathomechanisms of mood disorders emphasised that functional abnormalities of tripartite synaptic transmission play important roles in the pathophysiology of mood disorders. At first glance, the enhancement of astroglial connexin seems to contribute to antidepressant and mood-stabilising effects, but in reality, antidepressive and mood-stabilising actions are mediated by more complicated interactions associated with the astroglial gap junction and hemichannel. Indeed, several depressive mood-inducing stress stimulations suppress connexin43 expression and astroglial gap junction function, but enhance astroglial hemichannel activity. On the other hand, monoamine transporter-inhibiting antidepressants suppress astroglial hemichannel activity and enhance astroglial gap junction function, whereas several non-antidepressant mood stabilisers activate astroglial hemichannel activity. Based on preclinical findings, in this review, we summarise the effects of antidepressants, mood-stabilising antipsychotics, and anticonvulsants on astroglial connexin, and then, to establish a novel strategy for treatment of mood disorders, we reveal the current progress in psychopharmacology, changing the question from "what has been revealed?" to "what should be clarified?".

Astrocytes and Glutamine Synthetase in Epileptogenesis

The cellular, molecular, and metabolic mechanisms that underlie the development of mesial temporal lobe epilepsy are incompletely understood. Here we review the role of astrocytes in epilepsy development (a.k.a. epileptogenesis), particularly astrocyte pathologies related to: aquaporin 4, the inwardly rectifying potassium channel Kir4.1, monocarboxylate transporters MCT1 and MCT2, excitatory amino acid transporters EAAT1 and EAAT2, and glutamine synthetase. We propose that inhibition, dysfunction or loss of astrocytic glutamine synthetase is an important causative factor for some epilepsies, particularly mesial temporal lobe epilepsy and glioblastoma-associated epilepsy. We postulate that the regulatory mechanisms of glutamine synthetase as well as the downstream effects of glutamine synthetase dysfunction, represent attractive, new targets for antiepileptogenic interventions. Currently, no antiepileptogenic therapies are available for human use. The discovery of such interventions is important as it will fundamentally change the way we approach epilepsy by preventing the disease from ever becoming manifest after an epileptogenic insult to the brain.

Antiepileptic drug therapy in the elderly: a clinical pharmacological review

Seizure disorder is the third most common neurological disorder in the elderly after stroke and dementia. With the increasing geriatric population, the situation of clinicians seeing more and more elderly epilepsy patients is very likely. Not only is the diagnosis of epilepsy tedious in the elderly, its management raises many challenging issues for the treating physicians. Altered physiology, age-related decline in organ function, and plasma protein binding and altered pharmacodynamics make the elderly patients with seizure disorder a difficult group to treat. This is further complicated by the presence of comorbidities and polypharmacy which increase the chances of drug interactions. The adverse effects that might be tolerated well in younger populations may be disastrous for the aged. Although the newer antiepileptic drugs are found to have a favorable safety profile, there is relative scarcity of randomized-controlled trials involving older and newer antiepileptics in the geriatric population. This review tries to compile the available literature on management of epilepsy in the elderly population including evidence of safety and efficacy of newer and older antiepileptics with special reference to the 'geriatric giants'. It also deals with the interactions between antiepileptic medications and other commonly prescribed drugs in the elderly such as anti-hypertensives and antiischemic agents. The recommended guidelines of various international bodies are also analyzed from the perspective of elderly with seizure disorder.

[Suicidality in epilepsy: epidemiology and clinical risk factors]

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

[The structure of the non-psychotic mental disorders in patients with epilepsy with and without pharmacoressistance]

AIM

Patients with epilepsy (PE) develop persistent mental disorders identified as significant personal and affective disorders, especially of depressive and anxiety spectrum, observed in the interictal period of the disease. To study the frequency of non-psychotic mental disorders in patients with epilepsy, to specify the clinical features of non-psychotic affective disorders and to analyze the association of different variants of affective disorders with symptoms of drug-resistance in epilepsy (DRE).

MATERIAL AND METHODS

One hundred and sixty patients with epilepsy, including 80 patients with DRE and 80 patients with controlled epilepsy (CE), were studied using a battery of psychometric scales.

RESULTS AND CONCLUSION

The variety of depressive and anxious psychiatric condition was detected in 59.4% of PE, in 86.3% of patients with DRE and in 32.5% with CE. A clinical and psychopathological analysis of non-psychotic mental disorders showed that the frequency of affective disorders as well as great «structural complexity» and the depth of depressive and anxiety disorders were significantly higher in the group of patients with DRE compared to patients with CE. Patients with affective symptoms had earlier onset and the longer course of disease.

Non-psychotropic medication and risk of suicide or attempted suicide: a systematic review

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.

Inhibition of glutamine synthetase in the central nucleus of the amygdala induces anhedonic behavior and recurrent seizures in a rat model of mesial temporal lobe epilepsy

The prevalence of depression and suicide is increased in patients with mesial temporal lobe epilepsy (MTLE); however, the underlying mechanism remains unknown. Anhedonia, a core symptom of depression that is predictive of suicide, is common in patients with MTLE. Glutamine synthetase, an astrocytic enzyme that metabolizes glutamate and ammonia to glutamine, is reduced in the amygdala in patients with epilepsy and depression and in suicide victims. Here, we sought to develop a novel model of anhedonia in MTLE by testing the hypothesis that deficiency in glutamine synthetase in the central nucleus of the amygdala (CeA) leads to epilepsy and comorbid anhedonia. Nineteen male Sprague-Dawley rats were implanted with an osmotic pump infusing either the glutamine synthetase inhibitor methionine sulfoximine [MSO (n=12)] or phosphate buffered saline [PBS (n=7)] into the right CeA. Seizure activity was monitored by video-intracranial electroencephalogram (EEG) recordings for 21days after the onset of MSO infusion. Sucrose preference, a measure of anhedonia, was assessed after 21days. Methionine sulfoximine-infused rats exhibited recurrent seizures during the monitoring period and showed decreased sucrose preference over days when compared with PBS-infused rats (p<0.01). Water consumption did not differ between the PBS-treated group and the MSO-treated group. Neurons were lost in the CeA, but not the medial amygdala, lateral amygdala, basolateral amygdala, or the hilus of the dentate gyrus, in the MSO-treated rats. The results suggest that decreased glutamine synthetase activity in the CeA is a possible common cause of anhedonia and seizures in TLE. We propose that the MSO CeA model can be used for mechanistic studies that will lead to the development and testing of novel drugs to prevent seizures, depression, and suicide in patients with TLE.

[About the comorbidity of affective and conversion disorders in epilepsy]

In this literature review, special attention is drawn to the pathogenesis of conversion disorders in patients with epilepsy, in particular, with psychogenic non-epileptic seizures. Diagnostic issues and pharmacotherapy of affective and conversion disorders in patients with epilepsy is discussed.

Report of the WPA section of pharmacopsychiatry on the relationship of antiepileptic drugs with suicidality in epilepsy

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.

Pregabalin-induced self-harm behavior

Antiepileptic Drugs (AEDs) such as lamotrigine, gabapentin, and oxcarbazepine may have the potential to increase the risk of self-harm or suicidal behavior. We report a case of pregabalin-induced self-inflicted multiple injuries on forearm after its continuous use. This is an interesting adverse drug reaction (ADR) that is rare, unusual, and potentially serious.

How does antiepileptic drug induce suicidality? A case associated with levitracetam use

New antiepileptic drugs have been known to increase the risk of suicide. Among them, levitracetam is a widely used antiepileptic drug approved as a monotherapy treatment for partial seizures or as an adjunctive therapy for partial, myoclonic and generalized tonic-clonic seizures. It has been reported that the incidence of suicidal ideation during treatment with levitracetam was about 0.5-0.7%, but an explanation regarding a mechanism by which it causes suicidality is lacking. We made a multifaceted approach using the Hamilton Depression Rating Score (HDRS), the Hamilton Anxiety Rating Score (HARS), the Beck Hopelessness Scale (BHS), the Barratt Impulsiveness Scale (BIS), the Beck Scale for Suicidal Ideation (BSS) ideation daily and the Sheehan Suicidality Tracking Scale (SSTS) weekly in a patient taking levitracetam who acutely developed suicidal ideation after starting the medication. Suicidal ideation disappeared within 5 days of levitracetam discontinuation. We found that decreasing HDRS and BHS scores were correlated with BSS and SSTS scores. On the other hand, HARS and BIS did not change from their baselines. Our findings suggest that suicidality induced by an antiepileptic drug may be related to depression rather than anxiety and impulsiveness.

Depression and attempted suicide under pregabalin therapy

Originally developed for the treatment of epilepsy, pregabalin has become a compound with a wide spectrum of indications comprising anxiety disorders and chronic pain and is therefore largely prescribed. Thus, it is important for clinicians to be aware of rare, but serious adverse effects. The following report illustrates the case of a 20-year-old male with a severe depressive syndrome following pregabalin medication which even led to a suicide attempt.

Antiepileptic drugs and suicidality

The current study is a systematic review of the literature concerning the possible relationship of antiepileptics and suicide-related clinical features and behaviours. A MEDLINE search returned 863 papers but only five were chosen as relevant. A critical analysis of the Food and Drug Administration report is also included. Overall, the current review suggests there are no convincing data concerning a 'class effect' of antiepileptics in inducing any type of suicide-related behaviours. Further research is needed concerning topiramate, lamotrigine and maybe leviracetam. Clinicians are expected to inform patients and their families on the possible increased risk but it is important not to overemphasise the issue, since stopping or refusing to start antiepileptics may result in serious harm, including death of the patient. Future randomised controlled trials should specifically focus on issues concerning depression and suicidal thoughts in patients with epilepsy.

Antiepileptic drug monotherapy exposure and suicide-related behavior in older veterans

OBJECTIVES

To examine the association between antiepileptic drug (AED) receipt and suicide-related behavior (SRB) in older veterans.

DESIGN

Retrospective database analysis.

SETTING

Veterans Health Administration (VHA) inpatient and outpatient care.

PARTICIPANTS

Veterans aged 65 and older in 2004 to 2006.

MEASUREMENTS

SRB was identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes, and new AED monotherapy was identified using the VHA product variable in pharmacy data. Comorbid conditions and medications were also identified as potential confounders using previously validated algorithms. Cox proportional hazards models controlling for the propensity to receive AEDs examined the association between any AED exposure, specific AEDs, and time to SRB.

RESULTS

Within the eligible sample of 2.15 million individuals, 332 cases of SRB were found. Overall, 98% of participants were male, and 67% were non-Hispanic white. Affective disorders and severe psychiatric conditions were strongly associated with SRB and were included in the propensity score. AED exposure displayed a significant association with SRB (odds ratio = 4.10, 95% confidence interval (CI) = 3.85-6.63) after adjusting for propensity to receive AEDs. Stratified analyses found similar results for those with (hazard ratio (HR) = 4.00, 95% CI = 2.9-5.5) and without (HR = 4.57, 95% CI = 1.15-18.20) mental health comorbidities. Gabapentin, phenytoin, lamotrigine, levetiracetam, topiramate, and valproate were significantly associated with SRB.

CONCLUSION

Exposure to five common AEDs was associated with SRB in older VHA beneficiaries. Given the strong associations between psychiatric comorbidity and SRB, clinicians treating elderly adults should weigh this potential adverse effect into their consideration for treatment of those receiving AEDs. Particular attention should be given to depression and suicidality screening in people prescribed AEDs.

Management of psychotropic medication side effects in children and adolescents

This article is a review of several of the most concerning side effects of psychotropic medications in children and adolescents. An emphasis is placed on review of the prevalence, presentation, monitoring, and evidence-based management of these side effects.

A systematic review of validated methods for identifying suicide or suicidal ideation using administrative or claims data

PURPOSE

As part of the Mini-Sentinel pilot program, under contract with the Food and Drug Administration, an effort has been made to evaluate the validity of algorithms useful for identifying health outcomes of interest, including suicide and suicide attempt.

METHOD

Literature was reviewed to evaluate how well medical episodes associated with these events could be identified in administrative or claims data sets from the USA or Canada.

RESULTS

Six studies were found to include sufficient detail to assess performance characteristics of an algorithm on the basis of International Classification of Diseases, Ninth Revision, E-codes (950-959) for intentional self-injury. Medical records and death registry information were used to validate classification. Sensitivity ranged from 13.8% to 65%, and positive predictive value range from 4.0% to 100%. Study comparisons are difficult to interpret, however, as the studies differed substantially in many important elements, including design, sample, setting, and methods. Although algorithm performance varied widely, two studies located in prepaid medical plans reported that comparisons of database codes to medical charts could achieve good agreement.

CONCLUSIONS

Insufficient data exist to support specific recommendations regarding a preferred algorithm, and caution should be exercised in interpreting clinical and pharmacological epidemiological surveillance and research that rely on these codes as measures of suicide-related outcomes.

Antiepileptic drugs and suicidality

The risk of suicide in patients with epilepsy is significantly higher than the general population. There are many hypotheses as to the reasons for this, but the potential role of anti-epileptic drugs (AEDs) in increasing suicidality has recently been brought into question. In 2008, the U.S. Food and Drug Administration (FDA) published a warning after a meta-analysis of data from all clinical trials involving AEDs found a suicidality risk of 0.43 per 1000 patients in active drug arms of these clinical trials compared to a rate in the placebo arm of 0.22. While an increased risk for individual AEDs was found in two, the FDA decided to issue a warning for the entire AED class. While this decision and the meta-analysis findings have been considered controversial, and have created concern that this stated risk may dissuade use of AEDs by patients who would benefit from them, it has led to increased awareness of the risk of suicidality and psychiatric co-morbidity in this patient group. In this article, the association of epilepsy and AEDs with psychiatric disease and suicidality are reviewed, perspective as to the significance and limitations of the FDA’s findings are discussed, and some options for suicidality screening and their potential utility in clinical care are evaluated.

New approaches to the pharmacological treatment of obesity: can they break through the efficacy barrier?

In this review we assess the range of centrally active anorectics that are either in human clinical trials, or are likely to be so in the near future. We describe their weight loss efficacy, mode of action at both pharmacological and behavioural levels, where understood, together with the range of side effects that might be expected in clinical use. We have however evaluated these compounds against the considerably more rigorous criteria that are now being used by the Federal Drugs Agency and European Medicines Agency to decide approvals and market withdrawals. Several trends are evident. Recent advances in the understanding of energy balance control have resulted in the exploitation of a number of new targets, some of which have yielded promising data in clinical trials for weight loss. A second major trend is derived from the hypothesis that improved weight loss efficacy over current therapy is most likely to emerge from treatments targeting multiple mechanisms of energy balance control. This reasoning has led to the development of a number of new treatments for obesity where multiple mechanisms are targeted, either by a single molecule, such as tesofensine, or through drug combinations such as qnexa, contrave, empatic, and pramlintide+metreleptin. Many of these approaches also utilise advances in formulation technology to widen safety margins. Finally, the practicality of peptide therapies for obesity has become better validated in recent studies and this may allow more rapid exploitation of novel targets, rather than awaiting the development of orally available small molecules. We conclude that novel, more efficacious and better tolerated treatments for obesity may become available in the near future.

A model of cognitive decline and suicidal ideation in adults aging with HIV

The number of older adults with HIV continues to grow primarily because of the effectiveness of highly active antiretroviral therapy. Despite this welcomed benefit from pharmaceutical advances, aging with this disease presents an entirely new set of problems. The combination of aging and HIV can create a variety of stressors that may weaken one's resolve and further debilitate already compromised cognitive systems, which may increase rates of depression, suicidal ideation, and suicide. Studies indicate that older adults with HIV experience higher levels of depression and suicidal ideation than other older adults do or than younger adults with HIV do. Cognitive declines associated with both HIV and aging may provide insight into this phenomenon. A model of cognitive decline and suicidal ideation in adults aging with HIV is provided. Implications for nursing practice and research are discussed.

Review of topiramate for the treatment of epilepsy in elderly patients

Individuals over 65 years of age experience the new onset of seizures at a prevalence rate of roughly twice that of younger adults. Differences in physiology, need of concomitant medications, and liability for cognitive deficits in this population, make the choice of anticonvulsant drugs especially important. This paper reviews topiramate (TPM), a treatment for many types of seizures, with the above risks in mind. In particular, we discuss efficacy and pharmacokinetics with emphasis on the older patient, and adverse events in both the younger and older adult. With most studies of TPM-induced cognitive deficits having been performed in younger adults and volunteers, we discuss the implications for the older adult. Even in studies of younger individuals, up to 50% discontinue TPM because of intolerable cognitive deficits. Most studies find specific declines in working memory and verbal fluency. In conclusion, we give recommendations for use of this antiepileptic drug in this population.

Suicidal thoughts in epilepsy: a community-based study in Brazil

Epilepsy has been associated with increased risk of suicide; however, few studies have examined the relationship between epilepsy and suicidal behavior. The aims of this study were to evaluate the frequency of suicidal behavior in people with epilepsy and to identify characteristics that are associated with suicidal ideation in epilepsy. Of 171 people with epilepsy identified in a previous survey, 139 were included. A structured interview was conducted, and a second psychiatric evaluation was scheduled for those who agreed. The frequencies of suicidal thoughts, plans, and attempts during lifetime were 36.7, 18.2, and 12.1%, respectively. The following conditions were strongly associated with suicidal thoughts: anxiety (OR=3.3, 95% CI=1.4-7.5, P=0.001), depression (OR=4.8, 95% CI=1.9-12.5, P=0.001), and two or more standardized psychiatric diagnoses (OR=21.6, 95% CI=4.4-105.9, P<0.0001). Although specific characteristics of epilepsy were found to be related to suicidal thoughts, psychiatric diseases also play an essential role.

Wisconsin Card Sorting Test performance and impulsivity in patients with temporal lobe epilepsy: suicidal risk and suicide attempts

OBJECTIVE

The goal of the study described here was to determine if executive dysfunction and impulsivity are related to risk for suicide and suicide attempts in patients with temporal lobe epilepsy.

METHOD

Forty-two patients with temporal lobe epilepsy were recruited. A detailed medical history, neurological examination, serial EEGs, Mini-International Neuropsychiatric Interview, executive function, and MRI were assessed. Multiple regression analysis was carried out to examine predictive associations between clinical variables and Wisconsin Card Sorting Test measures.

RESULTS

Patients' scores on the Risk for Suicide Scale (n=24) were greater than 7, which means they had the highest relative risk for suicide attempts. Family history of psychiatric disease, current major depressive episode, left temporal lobe epilepsy, and perseverative responses and total errors on the Wisconsin Card Sorting Test increased by 6.3 and 7.5 suicide risk and suicide attempts, respectively. Executive dysfunction (specifically perseverative responses and more total errors) contributed greatly to suicide risk.

CONCLUSION

Executive performance has a major impact on suicide risk and suicide attempts in patients with temporal lobe epilepsy.

Treatment of neuropathic pain: an overview of recent guidelines

A number of different treatments for neuropathic pain have been studied, but the literature is sizable, rapidly evolving, and lacks important information about practical aspects of patient management. Under the auspices of the International Association for the Study of Pain (IASP) Neuropathic Pain Special Interest Group (NeuPSIG), a consensus process was used to develop evidence-based guidelines for the pharmacologic management of neuropathic pain that take into account clinical efficacy, adverse effects, impact on health-related quality of life, convenience, and costs. On the basis of randomized clinical trials, medications recommended as first-line treatments for neuropathic pain included certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha(2)-delta ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications that generally would be used as third-line treatments include certain other antidepressant and antiepileptic medications, topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists. Two other national and international associations recently published pharmacologic treatment guidelines for neuropathic pain, which are summarized and contrasted with the NeuPSIG recommendations. Recent guidelines for the use of neurostimulation for the treatment of neuropathic pain also are summarized. For all treatments for neuropathic pain, long-term studies, head-to-head comparisons, and studies of treatment combinations are a priority for future research.

A model of suicidal ideation in adults aging with HIV

Continuing advances in antiretroviral therapy are increasing survival and longevity for people living with HIV. However, factors related to depression and suicidal ideation associated with aging and HIV may mean that the synergistic effects of aging with HIV could place many adults at undue risk for these conditions. Such factors include ageism and stigma, loneliness/decreased social support, neurological changes, declining health, fatigue, changes in appearance, and financial distress. Potential interventions that address these factors are needed to abate depression and prevent suicidal ideation. Nurses are in key positions to identify and intervene with HIV-infected and aging patients who may be at risk for depression and suicidal ideation.

Molecular pharmacodynamics, clinical therapeutics, and pharmacokinetics of topiramate

Topiramate (TPM; TOPAMAX) is a broad-spectrum antiepileptic drug (AED) that is approved in many world markets for preventing or reducing the frequency of epileptic seizures (as monotherapy or adjunctive therapy), and for the prophylaxis of migraine. TPM, a sulfamate derivative of the naturally occurring sugar D-fructose, possesses several pharmacodynamic properties that may contribute to its clinically useful attributes, and to its observed adverse effects. The sulfamate moiety is essential, but not sufficient, for its pharmacodynamic properties. In this review, we discuss the known pharmacodynamic and pharmacokinetic properties of TPM, as well as its various clinically beneficial and adverse effects.

Depression and suicide in epileptic victims: a population-based study of suicide victims during the years 1988-2002 in northern Finland

Patients with epilepsy are known to have comorbid affective disorders and a higher risk for suicide compared with the general population. Epilepsy, depression, and suicidal behavior have been shown to have common pathogenic mechanisms in their etiology. We evaluated the association between epilepsy, suicidal behavior, and depression by using the comprehensive database of all suicides (n=1877) committed in northern Finland during the years 1988-2002 with information on all hospital-treated somatic and psychiatric disorders. Hospital-treated epilepsy occurred in 1.3% of the victims. Compared with other suicide victims, those with epilepsy were more often female, were older, and had significantly more often suffered from depression. Epilepsy was first diagnosed 8.8 (3.9-11.6) years before suicide, and depression, about 1 year after epilepsy diagnosis. Interictal depression among patients with chronic epilepsy is often classified as atypical or chronic depression, or it can mimic a dysthymic disorder. Therefore, diagnosis and treatment of depression among patients with epilepsy constitute a great challenge in clinical practice.

Suicidal ideation in epilepsy and levetiracetam therapy

There is little literature on a possible link between the use of antiepileptic drugs (AEDs) and the occurrence of suicidal ideation. Nevertheless, its occurrence needs to be promptly recognized because it may trigger suicidal attempts. We retrospectively evaluated a case registry of 517 patients taking levetiracetam (LEV) for suicidal ideation, looking at possible clinical variables involved. Suicidal ideation was reported by four patients (0.7%). All cases occurred in the context of a mood disorder presenting early during LEV therapy. Psychopathological characteristics of suicidal ideation were consistent in all subjects and similar to some features that are described as typical of the so-called interictal dysphoric disorder of epilepsy.