Study Suggests Role for Suicide Screening in All Youths With Epilepsy

Pediatric patients with epilepsy appear to have higher rates of depression, anxiety and suicidal thoughts than previously recognized, indicates a Cleveland Clinic study recently published in Epilepsy & Behavior and presented at the American Epilepsy Society’s virtual annual meeting last month. The findings argue for suicide screening in all children and youths with epilepsy, even those with no known mental health history, the researchers conclude.

“Suicidality is a life-threatening condition that can exist in the absence of an established psychiatric comorbidity,” says the study’s senior author, Tatiana Falcone, MD, MPH, of Cleveland Clinic’s Center for Behavioral Health and Charles Schor Epilepsy Center. “Nevertheless, little is known about the prevalence of suicidality in children and youths with epilepsy who do not have a pre-existing diagnosis of depression or anxiety.”

“Compared with other studies, the percentage of children, adolescents and teens in our study who screened positive for anxiety, depression and suicidality was quite a bit higher than expected,” says lead author Anjali Dagar, MD, a clinical research fellow at Cleveland Clinic. “Although this was a screening and the diagnosis must be confirmed by a psychiatrist, our findings suggest that it is important to screen all children, adolescents and teens with epilepsy for underlying psychiatric issues, even when there may be no signs of concern.”

Study essentials

The researchers screened patients aged 9 to 18 years who attended Cleveland Clinic’s epilepsy clinic or underwent evaluation in the pediatric epilepsy monitoring unit, excluding those with a pre-existing psychiatric diagnosis. Overall, 119 patients qualified for inclusion; 55% were female and the mean age was 15.8 years.

Screening involved completion of the following validated scales, all of which were self-administered:

• Screen for Child Anxiety Related Emotional Disorders (SCARED), a 41-item instrument assessing anxiety
• Center for Epidemiological Studies Depression Scale for Children (CES-DC), a 20-item tool assessing depression
• Ask Suicide Screening Questions (ASQ), a four-question screen for identifying thoughts of suicide

Results: Surprisingly high prevalence rates

Among the 119 patients, 30.2% screened positive for anxiety on the SCARED tool, 39.5% were positive for depression based on the CES-DC tool and 10.9% gave at least one positive response on the four-item ASQ tool for suicidality.

The researchers note that these rates are considerably higher than the 19% prevalence of anxiety and 13% prevalence of depression in an earlier study of youths with epilepsy. They are much higher still than the 7% and 3% rates of anxiety and depression, respectively, among 2- to 17-year-olds in the general U.S. population, according to Centers for Disease Control and Prevention data. While anxiety and depression correlate with latent suicidality, the researchers point out, comparative data on suicidality in children and youths without these diagnoses are not available.

The study also evaluated correlations between scores on the various screening tools in the study. SCARED scores had a low positive correlation with ASQ scores (r = 0.32) but a moderate positive correlation with CES-DC scores (r = 0.64). CES-DC scores had a moderate positive correlated with ASQ scores (r = 0.52). All correlations were statistically significant (P ≤ 0.001).

A compelling case for screening

“Although further research in a larger, diverse cohort is needed to confirm these findings, our results make a compelling case for using psychiatry screening tests for all children and youths with epilepsy,” says Dr. Falcone. “Our findings of unrecognized suicidality in more than one of 10 patients without a previously recognized psychiatric disorder should be a wake-up call.”

“Early identification of anxiety, depression and suicidality in young epilepsy patients can enable earlier referral for psychiatric treatment,” adds Dr. Dagar. “That can have clear quality-of-life benefits and, in the case of suicidality, may save lives. And it may also increase the efficacy of epilepsy therapy, as psychiatric comorbidities are known to compromise appropriate epilepsy treatment. There are likely benefits on multiple fronts.”