Routine Screening for Suicidal Behavior in Youth with Epilepsy

By Tatiana Falcone, MD; Migle Staniskyte, BA; and Jane Timmons-Mitchell, PhD

Is it feasible to do mental health screening during pediatric epilepsy appointments, and can such screening identify patients at risk for suicide?

Those were questions that fueled the development of a depression screening algorithm by specialists in pediatric behavioral health and pediatric epilepsy in Cleveland Clinic’s Neurological Institute. We presented findings from the first 400 patients screened with this tool at the 2015 annual meeting of the American Epilepsy Society. Here we summarize those findings and discuss whether integrated mental healthcare and routine screening (every six months) for mood disorders and suicidal ideation can enhance identification referral, determine appropriate treatment and potentially save lives in children and youth with epilepsy (CYE).

Why mental health matters in pediatric epilepsy

Past studies point to increased levels of mental health issues in CYE, including elevated rates of depression, suicidal ideation and attempted suicide. Other studies have reported that there is typically a five-year gap from a patient’s first psychiatric symptoms to when he or she receives appropriate treatment.

The 2012 Institute of Medicine report, Epilepsy Across the Spectrum, identifies screening for psychiatric comorbidities in patients with epilepsy as a priority. Recognizing that patients with epilepsy often face barriers to obtaining proper treatment for psychiatric comorbidities, the report emphasizes the need for a specific treatment development plan coordinated among all of a patient’s care providers.

An algorithm for routine depression screening

In light of these issues, several years ago we set out to leverage the Knowledge Program©, a system developed by Cleveland Clinic’s Neurological Institute for collecting patient-generated data, to conduct psychiatric screening in Cleveland Clinic’s Pediatric Epilepsy Program. Used in the conjunction with the Epic electronic health record system, the Knowledge Program enables systematic collection of patient health status measures.

For CYE, screening begins with the Patient Health Questionnaire-2 (PHQ-2) and proceeds according to the algorithm in Figure 1, which we call the Depression Screen Algorithm. Briefly, patients with a PHQ-2 score ≥ 1 take the Center for Epidemiological Studies Depression Scale for Children (CES-DC). Patients with a CES-DC score ≥ 16 proceed to a suicide screen with psychiatry follow-up as detailed in the algorithm.

Figure 1. The Depression Screen Algorithm. (PHQ-2 = Patient Health Questionnaire-2; CES-DC = Center for Epidemiological Studies Depression Scale for Children)

Findings from the first 400 patients

Our analysis of the initial patients (and their families) screened using this algorithm included all eligible CYE seen by Cleveland Clinic’s Pediatric Epilepsy Program from 2008 to 2015. A total of 5,303 mental health screenings for 400 CYE were recorded. Each patient was screened at every visit, for an average of approximately 13 screens per patient.

Of the 400 CYE, 106 screened positive for suicidal ideation, yielding a base rate of 26.5 percent. This is higher than that of the overall youth population in Ohio, according to recent Ohio Department of Health statistics on self-reported suicide-related behavior. Those statistics show that, during the prior 12 months, 14 percent of the state’s high school students had considered suicide, 9 percent had made a suicide attempt and 4 percent had sustained an injury from a suicide attempt. Thus, our screening findings are consistent with prior evidence that CYE are at higher risk for suicidal thoughts and behavior relative to similar-age youth.

Of the 106 CYE who screened positive, 50.9 percent were male and 49.1 percent female.

Among these 106 patients, 12 patients were referred to the emergency department (ED), and 13 suicides were prevented. The 13 patients in whom suicide was prevented had the following profile:

• 9 female, 4 male
• All Caucasian
• Age range, 9 to 18 years (mean = 15.25; SD = 2.34)
• All reported suicidal ideation. The number of suicide attempts ranged from 0 to 3 (mean = 1; SD = 1.05), with a total of 12 suicide attempts.
• Half reported thoughts of harming others.
• All were taking selective serotonin reuptake inhibitors.
• Nine had been admitted to the pediatric psychiatry inpatient unit (mean = 2.56 admissions; SD = 1.74).
• Overall mean Screen for Child Anxiety Related Disorders score was 47.69 (significant for clinical anxiety).
• Overall mean Children’s Depression Inventory score was 88.3 (significant for depression).
• Mean Adverse Childhood Experiences score (for exposure to emotional trauma) was 2.
• Total number of visits to the ED for suicidal ideation or suicide attempts was 41 (mean, 3.1 per patient).

The comorbidities screen: An important step in enhancing care

Development of an algorithm that integrates pediatric epilepsy screening with psychiatry follow-up facilitated the routine screening of 400 CYE. Of these patients, 26.5 percent screened positive for suicidal ideation, which is higher than rates found in other studies of CYE.

As noted in the Institute of Medicine report, development and implementation of a thorough screening process for psychiatric comorbidities in CYE is an important next step in enhancing care. Our Depression Screen Algorithm proved to be useful in organizing and systematizing the screening process and further applying a proper treatment plan for CYE.

Since 2008, we have used the Impact of Childhood Neurologic Disability Scale and other scales to systematically screen CYE for depression, suicidal ideation and epilepsy issues that could impact quality of life. Screening is done in the 15 minutes before these patients see their epileptologist. Scores are implemented into the chart for viewing during the visit, with results that require further attention (e.g., at-risk status for suicide or a need for further depression screening) flagged with special colors.

We have successfully integrated this Knowledge Program-based screening into the regular appointment workflow in our outpatient epilepsy clinic for CYE and all other patients with epilepsy. Our experience shows that systematic screening of this type is feasible, and we believe these findings show it enhances the quality of care we provide. Indeed, caring for patients with epilepsy goes beyond seizure control, and addressing psychiatric comorbidities should be a priority in the management of all CYE.

Dr. Falcone is a child and adolescent psychiatrist with appointments in Cleveland Clinic’s Center for Behavioral Health and Epilepsy Center.

Ms. Staniskyte is a research coordinator with Cleveland Clinic’s Neurological Institute.

Dr. Timmons-Mitchell is a senior research associate with the Begun Center for Violence Prevention Research and Education at the Jack, Joseph and Morton Mandel School of Applied Sciences within Case Western Reserve University (CWRU), Cleveland. She is also an associate clinical professor of psychology at CWRU School of Medicine.