Risk Factors for Suicide in Epilepsy Patients
Risk Factors for Suicide in Epilepsy Patients
In the past, researchers focused mostly on epilepsy and seizure factors (type of seizures and location of epileptic region, seizure frequency, age of epilepsy onset and epilepsy duration, and severity of seizures), side effects of antiepileptic medications and efficacy of epilepsy therapy (antiepileptic toxicity and surgery outcomes), age, gender and various other social and vocational factors in order to assess quality of life in individuals with epilepsy. One possible explanation for increased suicidal ideation is that there is an association of social and vocational factors, including epilepsy risk factors in this chronic illness and consequent decreased quality of life. However, recent research evaluated the impact of psychiatric conditions in epilepsy patients on their health. It is well known that prevalence of depression in patients with epilepsy is significantly higher than in general population. Assessments of quality of life in epilepsy using specific inventories to examine the presence of recent depressive symptoms, such as the Beck Depression Inventory showed significant association between severity of depression in epilepsy patients with quality-of-life measures, rather more than with seizure factors; the more severe symptoms of depression are, the lower the overall quality of life is (Box 1).
The mechanism of suicidal behavior in epilepsy patients is still uncertain. The most common hypothesis has been related to an existing psychiatric comorbidity, such as depression or psychosis, iatrogenic factors, and various psychosocial aspects characteristic for the chronic epilepsy. Recent observations in depressed individuals using modern neuroimaging techniques and quantitative analyses have tried to explain a complex neurobiological mechanism for depression. These studies indicate that the underlying cause of depression, which is, in the majority of epilepsy patients, a condition associated with suicidal ideation, a specific aspect of brain dysfunction. Studies further suggest that there is a decreased regional cerebral glucose metabolism in the ventral, medial and lateral prefrontal cortex in depressed high-lethality suicide attempters. In addition, lower ventromedial prefrontal cortical activity was associated with lower lifetime impulsivity, higher suicidal intent and a higher lethality of suicide attempts. This group also found a widespread impairment of serotoninergic network in the prefrontal cortex of depressed individuals. These may indicate a brain dysfunction and disturbance in neurotransmitter networks as possible causes for depression that in some individuals may also produce suicidal behavior. It is still unclear whether this hypothesis may underlie suicidal behavior in epilepsy patients.
In order to find mechanisms of suicidal behavior, researchers have examined specific psychological constructs to examine an association of neuropsychiatric disorders with suicidal behavior. These constructs include the presence of hopelessness, anhedonia, impulsiveness and high emotional reactivity. A number of models of suicidal behavior have been proposed. For example, in the Interpersonal Theory of Suicide, interpersonal connectedness is found to be protective from suicidal behavior. In most studies, the presence of a psychiatric disorder is a consistently reported risk factor for suicidal ideation and behavior. Important risk factors for suicidal behavior are chronic illness, chronic pain or other severe physical illnesses. Epilepsy can occur during childhood, adolescence or in adults, and neurodegenerative diseases such as Parkinson's disease, vascular disease, Alzheimer's disease and dementia, primarily afflict the elderly. Multiple sclerosis and amyotrophic sclerosis usually occur in middle-aged individuals. In people of all ages, physical illnesses, depression and loss of important relationships are important risk factors for suicidal behaviors. Primary care health professionals can play an important role in suicide prevention among higher-risk patients including the patients with epilepsy. In a study by Isometsa et al., 41% of older adults had seen their primary care physician within 28 days of committing suicide. This finding is supported by a meta-analysis of 40 studies that almost 45% of people of various ages who committed suicide had contact with primary care providers within 1 month of the suicide. The availability and appropriate use of clinical care is important for the prevention of suicide behaviors.
Bruffaerts et al. reported that the help-seeking process of suicidal people is complex. People experiencing suicidal ideation often feel pessimistic and hopeless and they may not have positive expectations that treatment will be helpful for them. Once someone has decided to seek treatment, adherence is also important. A variety of strategies have been proposed to encourage people experiencing suicidal ideation to seek help, to provide referrals and to improve referral follow-through and attendance. For example, these strategies include a national network of suicide prevention crisis lines, including the National Suicide Prevention Lifeline in the USA. National strategies for suicide prevention need to be regularly improved as new scientific information becomes available.
Conclusion & Future Perspective
In the past, researchers focused mostly on epilepsy and seizure factors (type of seizures and location of epileptic region, seizure frequency, age of epilepsy onset and epilepsy duration, and severity of seizures), side effects of antiepileptic medications and efficacy of epilepsy therapy (antiepileptic toxicity and surgery outcomes), age, gender and various other social and vocational factors in order to assess quality of life in individuals with epilepsy. One possible explanation for increased suicidal ideation is that there is an association of social and vocational factors, including epilepsy risk factors in this chronic illness and consequent decreased quality of life. However, recent research evaluated the impact of psychiatric conditions in epilepsy patients on their health. It is well known that prevalence of depression in patients with epilepsy is significantly higher than in general population. Assessments of quality of life in epilepsy using specific inventories to examine the presence of recent depressive symptoms, such as the Beck Depression Inventory showed significant association between severity of depression in epilepsy patients with quality-of-life measures, rather more than with seizure factors; the more severe symptoms of depression are, the lower the overall quality of life is (Box 1).
The mechanism of suicidal behavior in epilepsy patients is still uncertain. The most common hypothesis has been related to an existing psychiatric comorbidity, such as depression or psychosis, iatrogenic factors, and various psychosocial aspects characteristic for the chronic epilepsy. Recent observations in depressed individuals using modern neuroimaging techniques and quantitative analyses have tried to explain a complex neurobiological mechanism for depression. These studies indicate that the underlying cause of depression, which is, in the majority of epilepsy patients, a condition associated with suicidal ideation, a specific aspect of brain dysfunction. Studies further suggest that there is a decreased regional cerebral glucose metabolism in the ventral, medial and lateral prefrontal cortex in depressed high-lethality suicide attempters. In addition, lower ventromedial prefrontal cortical activity was associated with lower lifetime impulsivity, higher suicidal intent and a higher lethality of suicide attempts. This group also found a widespread impairment of serotoninergic network in the prefrontal cortex of depressed individuals. These may indicate a brain dysfunction and disturbance in neurotransmitter networks as possible causes for depression that in some individuals may also produce suicidal behavior. It is still unclear whether this hypothesis may underlie suicidal behavior in epilepsy patients.
In order to find mechanisms of suicidal behavior, researchers have examined specific psychological constructs to examine an association of neuropsychiatric disorders with suicidal behavior. These constructs include the presence of hopelessness, anhedonia, impulsiveness and high emotional reactivity. A number of models of suicidal behavior have been proposed. For example, in the Interpersonal Theory of Suicide, interpersonal connectedness is found to be protective from suicidal behavior. In most studies, the presence of a psychiatric disorder is a consistently reported risk factor for suicidal ideation and behavior. Important risk factors for suicidal behavior are chronic illness, chronic pain or other severe physical illnesses. Epilepsy can occur during childhood, adolescence or in adults, and neurodegenerative diseases such as Parkinson's disease, vascular disease, Alzheimer's disease and dementia, primarily afflict the elderly. Multiple sclerosis and amyotrophic sclerosis usually occur in middle-aged individuals. In people of all ages, physical illnesses, depression and loss of important relationships are important risk factors for suicidal behaviors. Primary care health professionals can play an important role in suicide prevention among higher-risk patients including the patients with epilepsy. In a study by Isometsa et al., 41% of older adults had seen their primary care physician within 28 days of committing suicide. This finding is supported by a meta-analysis of 40 studies that almost 45% of people of various ages who committed suicide had contact with primary care providers within 1 month of the suicide. The availability and appropriate use of clinical care is important for the prevention of suicide behaviors.
Bruffaerts et al. reported that the help-seeking process of suicidal people is complex. People experiencing suicidal ideation often feel pessimistic and hopeless and they may not have positive expectations that treatment will be helpful for them. Once someone has decided to seek treatment, adherence is also important. A variety of strategies have been proposed to encourage people experiencing suicidal ideation to seek help, to provide referrals and to improve referral follow-through and attendance. For example, these strategies include a national network of suicide prevention crisis lines, including the National Suicide Prevention Lifeline in the USA. National strategies for suicide prevention need to be regularly improved as new scientific information becomes available.
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