Epilepsy and risk of suicide: a population-based case–control study

doi:10.1016/S1474-4422(07)70175-8

The Lancet Neurology

Volume 6, Issue 8, August 2007, Pages 693-698

https://doi.org/10.1016/S1474-4422(07)70175-8 Get rights and content

Summary

Background

Studies have linked epilepsy with an increased suicide risk, but the association might be modified by psychiatric, demographic, and socioeconomic factors.

Methods

Suicide cases were identified in the Cause of Death Register in Denmark from 1981 to 1997. Up to 20 controls, matched by sex, birth year, and calendar date, were assigned to each suicide case.

Findings

We identified 21 169 cases of suicide and 423 128 controls. 492 (2·32%) individuals who committed suicide had epilepsy compared with 3140 (0·74%) controls, corresponding to a three times higher risk (rate ratio [RR] 3·17 [95% CI 2·88–3·50]; p<0·0001). The RR remained high after excluding those with a history of psychiatric disease and adjusting for socioeconomic factors (1·99, 1·71–2·32; p<0·0001). The highest risk of suicide was identified in patients with epilepsy and comorbid psychiatric disease, even after adjusting for socioeconomic factors (13·7, 11·8–16·0; p<0·0001). In individuals with epilepsy, the highest risk of suicide was found during the first half year after diagnosis was made (5·35, 3·43–8·33; p<0·0001), and was especially high in those with a history of comorbid psychiatric disease (29·2, 16·4–51·9; p<0·0001).

Interpretation

Individuals with epilepsy have a higher risk of suicide, even if coexisting psychiatric disease, demographic differences, and socioeconomic factors are taken into account. Our study identifies people with newly diagnosed epilepsy as a vulnerable group that require special attention.

Introduction

Individuals with epilepsy have a two to four times increased mortality compared with the general population.¹ This excess mortality is only partly explained by causative factors such as brain tumours, stroke, or head trauma.² Cohort studies from the UK³ and Sweden4, 5 have found a three to five times increased risk of suicide among individuals with epilepsy, but most studies were small.1, 4, 6, 7, 8, 9 A recent meta-analysis identified 29 studies, including 187 suicides, in people with a history of epilepsy.¹⁰ The US Department of Health and Human Services has concluded that there is insufficient evidence to suggest that patients with medically refractory epilepsy have an increased risk of suicide and have requested that cohort studies with sufficient size and follow-up should be done.¹¹

There is a strong association between epilepsy and psychiatric disease,¹² and psychiatric illness is one of the strongest risk factors for suicide.¹³ An increased risk of suicide among epilepsy patients with mental illness and use of antipsychotic drugs has been reported.4, 7, 9, 14, 15 However, no studies have been large enough to assess whether the risk of suicide is modified by history of psychiatric disease in patients with epilepsy.

Socioeconomic and demographic factors clearly play a part in the risk of suicide.15, 16, 17 Patients with epilepsy have lower quality of life and socioeconomic conditions compared with the general population, but whether these factors modify the risk of suicide in patients with epilepsy has yet to be studied.

We did a large population-based case–control study of the association between epilepsy and suicide, and took psychiatric disease, and demographic and socioeconomic factors into account.

Section snippets

Data sources

Epilepsy, psychiatric, socioeconomic, and demographic data were retrieved and merged from five nationwide longitudinal registries in Denmark: the Danish National Hospital Register, the Cause of Death Register, the Danish Psychiatric Central Register, the Danish Integrated Database for Labour Market Research (IDA database), and the Danish Civil Registration System.

The Danish National Hospital Register provided information on epilepsy for hospital inpatients (1980–1997) and outpatients

Results

We identified 21 169 suicide cases and 423 128 controls. Among individuals who committed suicide, 492 (2·32%) had a history of epilepsy compared with 3140 (0·74%) controls. People with epilepsy had a three times higher risk of suicide (RR 3·17 [95% CI 2·88–3·50]; p<0·0001) compared with people with no such history. The risk of suicide in the general population is known to increase with age,²⁵ but the increase was not as strong among patients with epilepsy (0·985, 0·980–0·991; p<0·0001). From

Discussion

In this population-based study, we identified a more than three times higher risk of suicide among people with a diagnosis of epilepsy. Our results are in keeping with those of some previous studies,1, 3, 4, 5 but not all.27, 28

The major strengths of this study are the size, the population-based nature, the minor loss to follow up, and the opportunity to adjust for comorbid psychiatric disease and underlying demographic and socioeconomic factors. The most important confounding factor for the

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Risk factors for anxiety in patients with epilepsy: A meta-analysis
2024, Epilepsy and Behavior
Epilepsy is a very common neurological disease, and it is important to focus on both controlling seizures and alleviating the psychological problems associated with this disease.Anxiety is an important risk factor for epilepsy and seriously affects the quality of life of patients with epilepsy (PWE). However, several risk factors for anxiety in PWE are relatively controversial and understudied. This meta-analysis was performed to identify potential risk factors for anxiety in PWE with the aim of reducing the incidence of anxiety and improving the quality of life among the individuals.
The PubMed, Embase and Cochrane Library databases were systematically searched up to July 2023 to find eligible original English studies. All the search results were reviewed based on our inclusion and exclusion criteria. We calculated the combined odds ratios (ORs), standard mean differences (SMDs) and their corresponding 95% confidence intervals (CIs) to evaluate the effect of the included risk factors on anxiety in PWE.
Twenty-four studies involving 5,403 PWE were ultimately included. The pooled results of our meta-analysis showed that female sex (OR = 1.67; 95 % CI: 1.30,2.15; p < 0.001), unmarried/divorced/widowed (OR = 0.83; 95 % CI: 0.72,0.96; p = 0.011), low socioeconomic status (OR = 0.47; 95 % CI: 0.33,0.67; p < 0.001), education levels below high school (OR = 1.74; 95 % CI: 1.36,2.23; p < 0.001), a history of trauma (OR = 2.53; 95 % CI: 1.69,3.78; p < 0.001), monotherapy (OR = 0.49; 95 % CI: 0.39,0.62; p < 0.001), AED-induced psychiatric side effects (OR = 2.45; 95 % CI: 1.20,4.98); p = 0.014), depression (OR = 5.45 95 % CI: 2.49,11.94; p < 0.001), a history of suicide (OR = 3.56; 95 % CI: 1.72,7.38; p = 0.001), and illness-related shame (OR = 2.76; 95 % CI: 2.17,3.52; p < 0.001) were risk factors for anxiety.
This meta-analysis showed that female, unmarried, low socioeconomic status, education level below senior high school, a history of trauma, monotherapy, AED-induced psychiatric side effects, depression, a history of suicide, and shame were risk factors for anxiety in PWE. However, further research is needed to determine the effect of other potential risk factors on anxiety in PWE. In addition, most of the studies included in this meta-analysis were not uniform in scale, and the risk factors were not comprehensive; therefore, larger prospective studies in different countries are needed to further investigate these risk factors.
Suicide risk of chronic diseases and comorbidities: A Korean case-control study
2024, Journal of Affective Disorders
Chronic diseases including mental disorders have been associated with suicide. This study broadens the approach by incorporating a comprehensive list of chronic diseases and a context of comorbidities and explored their associations with suicide.
Data-linkage between death registry and Korean National Health Insurance data was conducted. Suicide cases (n = 64,099) between 2009 and 2013 were 1:4 matched for gender and age to an alive control (n = 256,396). A total of 92 individual diseases of 9 broad categories were identified from insurance claims data. Conditional logistic regression was applied to assess the associations, adjusting for mental and behavioral disorders and socioeconomic status.
Suicide cases frequently experienced chronic diseases (90.0 %) and comorbidities (74.6 %). Chronic diseases greatly increased suicide risk and, among these, mental and behavioral disorders showed the highest suicide risk (OR = 7.53, 95 % CI = 7.32–7.74) followed by cardiovascular (OR = 3.36, 95 % CI = 3.26–3.47). For individual diseases, gastritis and duodenitis were most prevalent (68.1 %) among suicide cases but depressive disorder showed the highest risk (OR = 4.95, 95 % CI = 4.79–5.12). Suicide risk was strong in comorbid status sometimes comparable to odds for mental and behavioral disorder alone (e.g., OR for cardiovascular and eye vision-related diseases = 4.01, 95 % CI = 3.86–4.17).
Differentiation of comorbidity was limited to pairs between major disease categories, neglecting the heterogeneity within categories.
Chronic diseases, in particular comorbidity, showed strong associations with suicide. This suggests that those with comorbidities feel that they are pushed to the extreme line, supporting comprehensive interventions for them to address wider reasons including psychological and social problems, besides medical problems.
Predictors of clinically significant anhedonia in refractory epilepsy
2024, Journal of the Neurological Sciences
Background: Anhedonia, the inability to feel pleasure or motivation for reward, is a core feature of depression in epilepsy, but can occur independent from depression. It is reported in over a third of people with epilepsy and has a significant impact on quality of life. Objectives: This study determined whether specific features of medication refractory epilepsy are predictive of anhedonia. Design: We assessed 267 patients with medication refractory epilepsy for anhedonia, primarily using the clinically validated Snaith-Hamilton Pleasure Scale (SHAPS) scale. Methods: Patients with clinically significant anhedonia were compared with those without for key demographics, epilepsy characteristics and medication using a logistic regression analysis. Results: We found that seizure frequency (p < 0.01) but not duration of epilepsy was significantly associated with anhedonia. We also found that benzodiazepine use was significantly associated (p = 0.01) with anhedonia, and levetiracetam/brivaracetam and sodium valproate were significantly negatively associated with anhedonia (0.01 and 0.03 respectively). Conclusion: High seizure burden in medication refractory epilepsy is significantly associated with anhedonia. Specific antiseizure medications are also associated with the development of anhedonia, but it is unclear whether their use is causative or influenced by the presence of anhedonia.
Risk of suicide and religious or spiritual beliefs in Brazilian adult patients with epilepsy
2023, Epilepsy and Behavior
In epilepsy, suicidal behavior is higher compared with the general population.
To assess the relationship between suicide risk, religiosity or spirituality, and clinical variables in adult patients with epilepsy (PWE).
The data from the suicide module of the Mini International Neuropsychiatric Interview (MINI) were related to scores on the Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS-P) and the Hospital Anxiety and Depression Scale (HADS), as well as clinical variables in 96 adults PWE, with a significance level of p < 0.05.
The study included 49 patients with temporal lobe epilepsy with hippocampal sclerosis (TLE-HS) and 47 cases of other epilepsies. The presence of suicide risk in the MINI was observed in 43 (44.7%) cases. Suicide risk was associated with an earlier age of epilepsy onset, higher seizure frequency, neurological abnormalities, and higher scores on the HADS-A and HADS-D scales. Suicide risk was low in 33 (76.7%) cases and moderate or high in 10 (23.2%) cases. Higher suicide risk was associated with higher education levels, focal structural epilepsy, use of ≥2 antiseizure medications, neurological abnormalities, anxiety, and dimensions such as daily spiritual experiences, religious or spiritual coping, organizational religiousness, and total score in the BMMRS-P.
A high number of patients with epilepsy exhibited suicide risk, with epilepsy-related variables, the presence of anxiety, and perceived lower belongingness and social support from religiosity or spirituality anxiety being associated with a higher risk. The social support provided by religiosity/spirituality may be a non-clinical factor associated with suicidal behavior. Suicide in epilepsy is associated with a complex interaction of multidimensional factors.
Resilience predicts and modulates anxiety severity in people with epilepsy
2023, Epilepsy and Behavior
Anxiety is one of the most relevant psychiatric comorbidities in people with epilepsy (PwE). The role of resilience (RES) in the development of anxiety is not well understood. We purposed to better characterize RES impact on anxiety severity in PwE.
One hundred and seventy-six PwE underwent online surveys including a collection of socio-demographic, seizure-related, and psychological variables. PwE were grouped according to the data collected; anxiety levels were compared through non-parametric statistics. Hierarchical regression analysis (HRA) and logistic regression were performed to characterize RES contribute in predicting the presence and the severity of anxiety. Mediation/moderation analysis was performed to evaluate causal effects among RES, depression, and anxiety.
Anxiety did not differ according to socio-demographic and seizure-related variables, exemption for the presence of drug-related adverse effects. Depression, RES, and sleep quality provided the major contribute on anxiety variance. The addiction of RES level in HRA and logistic regression provided a significant increase of R-squared value (p-value = 0.02) and of area under the curve (p-value = 0.03), respectively. RES modulated depression/anxiety relationship (p-value < 0.001), whereas depression did not mediate RES/anxiety correlation (p-value = 0.68).
We demonstrated that RES is a significant independent predictor of anxiety in PwE and is able to modulate depression impact on anxiety. Moreover, we confirmed the relevance of depression and sleep quality on anxiety severity.
Factors related to the severity of obsessive–compulsive symptoms and their impact on suicide risk in epileptic patients
2023, Epilepsy and Behavior
To explore relevant factors for the severity of obsessive–compulsive symptoms (OCSs) in adult epileptic patients and investigate whether the severity of OCSs is a mediator in the relationship between depressive/anxiety symptoms and suicide risk in epileptic patients.
This was a cross-sectional study from a hospital in Northeast China. Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Neurological Disorders Depression Inventory for Epilepsy (NDDIE), Generalized Anxiety Disorder (GAD-7), and Nurses’ Global Assessment of Suicide Risk (NGASR) were used to assess the severity of OCSs, depressive symptoms, anxiety symptoms, and suicide risk in epileptic patients, respectively. The independent factors of the severity of OCSs and their mediating effects in the relationship between depressive/anxiety symptoms and suicide risk were evaluated by regression analyses and mediator models, respectively.
NDDIE scores (β = 0.404, p < 0.001), GAD-7 scores (β = 0.247, p = 0.009), and polytherapy (β = 0.119, p = 0.032) were the independent factors of Y-BOCS scores. The Y-BOCS scores partially mediated the relationship between GAD-7 scores and NGASR scores (standardized coefficients of indirect effect = 0.109, Bootstrap 95% CI = 0.024 to 0.214). Still, they did not mediate the relationship between NDDIE scores and NGASR scores (standardized coefficients of indirect effect = 0.062, Bootstrap 95% CI = −0.024 to 0.169).
Depressive symptoms, anxiety symptoms, and polytherapy are independently associated with the severity of OCSs in epileptic patients. Depressive and anxiety symptoms mediate the effect of the severity of OCSs on suicide risk in epileptic patients completely.

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Fast track — ArticlesEpilepsy and risk of suicide: a population-based case–control study

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Data sources

Results

Discussion

Lancet

Epilepsy Behav

Lancet

Lancet

Lancet

Biol Psychiatry

Lancet

Lancet Neurol

Epilepsy Res

Psychosomatics

Epilepsy Behav

Cause-specific mortality in adults with unprovoked seizures. A population-based incidence cohort study

Neuroepidemiology

Mortality in epilepsy

J Neurol

Risk factors for suicide in epilepsy: a case control study

Epilepsia

Cause-specific mortality in epilepsy: a cohort study of more than 9,000 patients once hospitalized for epilepsy

Epilepsia

Community-based study of mortality in children with epilepsy

Epilepsia

Ictal and psychiatric aspects of suicide in epileptic patients

Int J Psychiatry Med

The suicide rate of epilepsy

Acta Psychiatr Scand

Causative factors for suicide attempts by overdose in epileptics

Arch Neurol

Management of treatment-resistant epilepsy. Evidence report/technology assessment no. 77 [AHRQ publication no. 03-0028]

Fast track — Articles
Epilepsy and risk of suicide: a population-based case–control study