Cleveland Clinic psychiatrist Tatiana Falcone, MD, is a national expert focused on the crossroads of two conditions that are too often related and still regarded with uncertainty and suspicion: epilepsy and suicide. Consult QD caught up with Dr. Falcone after the American Psychiatric Association’s 2019 annual meeting, where she spoke on preventing suicide in the consult-liaison psychiatry service.
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Q: Why is suicide a particular concern in people with epilepsy?
A: The rate of suicide among patients with epilepsy is staggering — an estimated three to five times higher than in the general population.
This propensity to suicide is attributed to several factors, the most obvious being that people with epilepsy live under very difficult psychosocial circumstances. Many adults struggle to keep a job, and young people face misunderstanding and even bullying from peers at school. The resulting isolation, coupled with the unpredictability and lack of control inherent to a seizure disorder, make it no surprise that anxiety and depression feature prominently in epilepsy.
But epilepsy itself is also believed to contribute to mood disorders, likely because seizures — as well as head traumas that might result from them — damage brain tissue. The longer a person has had epilepsy and the more severe the problem, the higher the risk of suicide.
Finally, the availability of prescription medications provides patients with a means to harm themselves. The most common suicide method among people with epilepsy is overdosing on antiepileptic drugs.
Q: What’s your strategy to help prevent suicide in your patients?
A: First, I regularly screen all my patients with epilepsy for suicide risk — every six months is appropriate, and more often if the patient is deemed at elevated risk. I recommend the Ask Suicide Screening Questions (ASQ) tool, which takes only 10 minutes to administer and has been validated for teens and adults with epilepsy. Developed by the National Institute of Mental Health, it is available free online.
Individuals deemed at imminent risk of suicide are immediately referred for additional assessment.
For those deemed at low immediate risk but who express thoughts of anxiety or depression and have considered suicide in the past, I help develop coping strategies: What are things they can do to feel better when they are low? Together we come up with a list, which might include things like meditation exercises, taking a walk or watching a movie. Actually writing down such a plan or making a “hope box” — containing pictures of loved ones, positive notes and coping resources — can help with adherence.
We also discuss next steps if such techniques prove inadequate. The patient’s action plan must include a list of family, friends and healthcare providers they can call if they need help, as well as a 24/7 suicide prevention hotline number, and they must promise to follow through.
Q: What’s the role of medications?
A: That’s a great question, because there are a lot of controversies surrounding medications and epilepsy.
A big one concerns the FDA’s black-box warnings on antiepileptic drugs for increased risk of suicide and suicidal ideation. This association has not been proven to be causal; it’s well known that people with epilepsy have an increased suicide risk, but there is no clear proof that it’s caused or enhanced by their medications. We do know that the possible increased risk found in some studies is small and that it’s critical to a patient’s health to bring epilepsy under control and avoid seizures. It is important to screen for mood disorders, depression and anxiety in people with epilepsy, as these are the more likely causes of increased suicidality in this population.
The use of antidepressant medications is another hot topic. Many doctors are uncomfortable adding mood-altering drugs to antiepileptic medications, so they wishfully think, along with their patients, that depression will lift once epilepsy is brought under control. But multiple studies show that antidepressants are safe and effective in epilepsy and do not increase the risk of seizures. An exception is bupropion, which does lower the seizure threshold and should be avoided. And tricyclic antidepressants should be used with caution.
Q: Do you have special guidance for the pediatric population?
A: Definitely. There is a persisting stigma attached to epilepsy, so many parents encourage their children and teens to keep their condition a secret from teachers and peers. But I recommend the opposite: Be proactive, by educating students in the child’s classroom and developing an action plan with teachers and staff before a seizure occurs at school.
We created a series of videos and webinars related to pediatric epilepsy that are available free online and cover topics including how to deal with anxiety and tips for school. These resources provide a lot of practical advice for parents and healthcare providers.
Dr. Falcone is a psychiatrist with Cleveland Clinic’s Department of Psychiatry and Psychology and Epilepsy Center. She co-edited a textbook published in 2018, Suicide Prevention: A Practical Guide for the Practitioner, with a chapter devoted to children and adults with epilepsy.