Feature article: Depression and the Risk of Suicide in Epilepsy
For this issue, we sat down with Dr. Lorna Myers, clinical psychologist with 15 plus years of experience, to discuss a very important topic that is faced by a number of those living with epilepsy: depression and suicidal ideation. Dr. Lorna Myers earned her Ph.D. in Clinical Psychology at the City University of New York, completed her hospital-based training at Bellevue Medical Center and then went on to complete a fellowship in neuropsychology. She joined the Northeast Regional Epilepsy Group nearly 10 years ago.
Depression and suicide are all too often avoided by health professionals and loved ones because it is disturbing and frightening and it may not be clear what needs to be done about it if confirmed. However, depression is in fact one of the more common psychiatric disorders that can accompany epilepsy along with increased risks for suicidal thoughts and actions. In this feature article, we are going to go over depression risk factors, theories as to why suicidal ideation might be more frequent in epilepsy, and also go over recommendations for prevention and suggestions on how to respond if you suspect someone is feeling suicidal.
Are persons with epilepsy at a higher risk for depression and suicidal ideation than the general population?
Mood disorders are the most common psychiatric comorbidities associated with epilepsy. One of the most concerning symptoms of depression is increased hopelessness which leads to suicidal thoughts and sometimes, the decision to act on these. It is believed that people with epilepsy (PWEs) are three to five times more likely to commit suicide than the general population.
A special population is that of newly diagnosed PWEs. It has been observed that these patients are much more likely to commit suicide than those who have been living with the diagnosis longer. This may be due to the suddenness of the diagnosis, some of the life-altering restrictions (i.e. driving) that may be imposed, and due to the person being unaware of all the good treatment options that exist including medications and medical devices. Therefore, it is essential to be alert for mood changes when your loved one has just recently been given a diagnosis of epilepsy.
Are there some people who are more at risk of suicidal ideation?
Clearly, if the patient has already been carrying a psychiatric disorder, for example, mood disorder or personality disorder, there may be an even greater risk for suicidal ideation, suicide attempts and completed suicides.
There is also obviously a higher risk for suicide attempts in those who have made previous suicide attempts.
Do those with epilepsy have a higher risk of having psychiatric conditions? Why?
Yes, higher rates of mood disorders (e.g. depression) and anxiety disorders have been observed in PWEs. There are likely a number of reasons for this, including that some of the areas of the brain that are affected by electrical discharges during the seizures are also involved in mood and behavior. This is why changes in mood might be evident before, during, after or in between seizures for some PWEs. In addition, some anti-epileptic medications may have side effects that impact mood. Another reason for increased mood problems in epilepsy has to do with the social and functional impact that epilepsy may have on the person living with the seizures. In other words, having seizures occur randomly can affect independence, limiting going out of the home alone, leading to the loss of driving privileges, may require major shifts in work or school activities, may be dangerous and frightening, etc. Public ignorance and stigma associated to epilepsy further compounds the problem. Therefore, depression may be an understandable development of epilepsy but also clearly one that can be effectively treated. Careful screening of PWEs for depression, anxiety and suicidal ideation should be conducted regularly and actively by health professionals.
How can suicide be prevented?
It can be extremely difficult to predict suicidality especially if the patient doesn't want to disclose this. However, most people who are contemplating suicide as an option are conflicted about the possibility of carrying this through and may give clues to those around them. In particular, newly diagnosed PWEs should be carefully screened for depression and other psychiatric conditions. A thorough psychiatric and psychosocial assessment should be made including an evaluation of current emotional symptoms, personal psychiatric history, and family psychiatric history. If a risk for suicide is detected, the patient should be assisted in finding appropriate treatment, a referral to a psychiatrist or even walking the patient to the emergency room for hospitalization might be necessary. It is important to remember that what seems like the "only option" when depressed, once the depression lifts seems terrifying to the same patient. I have had countless patients tell me after their depression improved that they cannot recognize themselves and the thoughts they were having when they were suicidal. They are always grateful that the suicidal intention they held so strongly at that time was cut short by an intervention, treatment, and even sometimes, hospitalization.
Some medical practices screen regularly for psychiatric symptoms. There are some brief self-report measures that can be administered in the waiting room. Also, the good old-fashioned direct questions by the nurse or doctor during the exam can also reveal depressive symptoms.
Even though antidepressant medication has received a bad rap, there is mounting evidence that selective serotonin reuptake inhibitors (SSRIs), can be used in adults with only a small risk of seizure increase. This can be discussed with the treating epileptologist.
What should a loved one do if they believe their loved one is depressed and having suicidal thoughts?
If your loved one is showing symptoms of depression (sad mood, tearfulness, loss of interest in activities that used to give her/him pleasure, changes in sleep and appetite, hopelessness) you should encourage her/him to look for psychological help. Probably, the best option for this is your loved one's epilepsy team. The doctor may work directly with a psychologist or psychiatrist who is also familiar with epilepsy and can assess and treat if needed. You may want to call the office for a referral or go in to the next appointment with your loved one to make sure the doctor understands what you have been observing. Another option is to consult with your health insurance and obtain a list of mental health providers. You can also look for a psychologist on the American Psychological Association's website (find a psychologist tab: http://locator.apa.org/?_ga=2.37436320.1675213536.1495289202-466698497.1466009902).
If your loved one confides in you that he/she is thinking about suicide as an option, this is an emergency and must be taken seriously every time. Sometimes a person has threatened with suicide before and hasn't acted on it, which leads loved ones to disregard the suicidal ideation reported. Don't! People sometimes work their way towards a suicidal attempt and previous warnings may have been doing just this. If someone says to you that they are considering suicide, you need to get them to a doctor.
Specific things to look out for if suicidality is a concern:
Make sure that objects that might be dangerous (used in a suicide attempt) are kept under lock and key. For example, knives, firearms, or large amounts of medications (including anti-epileptic medications).
Make sure the person is not left alone.
What can you say to someone diagnosed with epilepsy regarding this topic of depression?
If you notice your mood has worsened, you feel hopeless, you are sleeping much more or less, your appetite has changed (eating much more or having no appetite), or maybe you are thinking that life isn't worth living: this is DEPRESSION. Depression is an ILLNESS that requires professional treatment. Clinical depression is not a weakness, nor can you just "pull yourself up by your bootstraps;" it is an illness that can wreak havoc on your quality of life, your physical health and your social relations. Depression is not just something you should learn to live with because there are many ways to improve it and when it lifts, you regain huge portions of your life. It is also important to remember that major depression can worsen your seizures so it is especially important to pay attention to symptoms of depression and to discuss with your epileptologist.
Thank you, Dr. Myers, for sitting down to go over these important issues that are hard but necessary to talk about.
