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Suicidal ideation may follow epileptic seizures.

BOSTON -- Some epilepsy patients, particularly those with a history of depression, are at increased risk of postictal suicidal ideation, a study has shown. The results are consistent with previous reports of elevated lifetime prevalence rates of suicide among people with epilepsy, suggesting that a thorough psychiatric evaluation for patients with epilepsy should be standard practice, reported Dr. Hillary R. Gross-Kanner and Dr. Andres M. Kanner of Rush-Presbyterian-St. Luke's Medical Center in Chicago.

Of 100 consecutive patients with drug-resistant partial epilepsy enrolled in the study, 13 experienced postictal suicidal ideation (PSI) with a median estimated duration of 24 hours, Dr. Gross-Kanner said at the annual meeting of the American Epilepsy Society.

The investigators used a 42-item questionnaire to identify the presence and clinical characteristics of postictal psychiatric and cognitive symptoms experienced by study patients during the 3 months before the survey.

The questionnaire established the prevalence, frequency of occurrence, and median estimated duration of depressive symptoms (feelings of hopelessness, and helplessness, crying bouts, self-deprecation, guilt, hypomania, psychosis, and neurovegetative symptoms) during the postictal period, defined as the 72 hours after a seizure or cluster of seizures. Only those symptoms that occurred after more than half of the seizures were included for analysis.

None of the patients enrolled in the study were taking psychotropic drugs, and all underwent a psychiatric evaluation to identify any psychiatric history of mood, anxiety, psychosis, attention-deficit disorder, and past hospitalizations. All of the patients also underwent a prolonged video-EEG monitoring study, high-resolution magnetic resonance imaging, and neuropsychological studies.

A history of depression and of psychiatric hospitalization were significantly and independently associated with PSI. The occurrence of PSI also correlated significantly with postictal feelings of hopelessness and helplessness, crying bouts, self-deprecation, and guilt. All associated depressive symptoms had a median estimated duration of 24 hours except crying bouts (median duration 6 hours).

None of the neurologic or epilepsy-related variables such as the location of seizure focus, types of seizures, seizure frequency, seizures in clusters, or neuroradiologic abnormalities were significantly associated with the occurrence of PSI.

Psychiatric comorbidity is common among people with epilepsy, Dr. Kanner said in an interview. "Rates of mood disorders, especially major depression, have consistently been reported to be elevated, and the risk of suicide has been estimated to be 10 times higher than in the general population."

Epilepsy has been established as a risk for depression, but "recent studies suggest that a history of depression is associated with a four- to sixfold increased risk of developing epilepsy, indicating either a possible bidirectional relationship between the two or common pathogenic mechanisms that facilitate the occurrence of one in the presence of the other," Dr. Kanner noted.

The clinical presentation of depressive disorders in epilepsy can be identical to that of nonepileptic patients and can include major depression, bipolar and dysthymic disorders, and minor depression. In some patients, however, the clinical features of depression do not meet any of the DSM-IV Axis I categories.

"Depression may be iatrogenically induced with various antiepileptic drugs used to treat the seizure disorder or after surgical treatment of intractable epilepsy," he noted.

In terms of suicide risk, other potential factors to be considered include family issues, physical health, personality, life stress, previous suicidal behavior, and access to firearms. The suicidality module of the Mini International Neuropsychiatric Interview is a practical tool to help quantify current suicide risk. "A thorough evaluation based on these considerations helps to determine the appropriate level of intervention," Dr. Kanner said.


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Title Annotation:NeuroPsychiatric Medicine
Author:Mahoney, Diana
Publication:Clinical Psychiatry News
Date:Feb 1, 2004
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