Preventing suicide in epilepsy

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Preventing suicide in epilepsy patients consists of effectively treating both the dysphoric disorder and the psychosis of the interictal phase (Blumer, 1997; Blumer et al., 2000; Blumer and Zielinski, 1988). We now treat both the patients with suicidal dysphoric moods and those with interictal psychoses with double antidepress-ant medication, enhanced if necessary with an atypical neuroleptic drug, e.g. with the combination of 100-150 mg imipramine, 20-40 mg paroxetine and 2-4 mg risperidone daily. The same treatment has been effective for patients with severe postictal depressive mood, although we have not had the occasion to treat a patient with ictal depression and suicidal intensity of the postictal phase. The dysphoric disorder is endogenous, and psychotherapy without pharmacotherapy leaves the patient with suicidal moods at risk.

The bias against using antidepressants for the psychiatric disorders of epilepsy on the grounds that they may lower the seizure threshold (McConnell and Duncan,

1998) is erroneous on both empirical and theoretical grounds. As our experience over some 15 years has shown, the modest amounts of antidepressant medication required do not increase seizure frequency in patients with chronic epilepsy whose interictal dysphoric disorder or psychosis indicates the presence of marked inhibition (Blumer, 1997; Blumer et al., 2000; Blumer and Zielinski, 1988). Gastaut et al. (1955) have pointed out that patients with temporal lobe epilepsy (in contrast to those with primary generalized epilepsy) show a higher interictal seizure threshold than do individuals without epilepsy. The proconvulsant effect of antidepressants does not provoke seizures but may serve to mitigate the psychotoxic effect of excessive inhibition. Avoiding antidepressants for a patient with suicidal dysphoric moods may have fatal consequences.

The 10739 patients with epilepsy seen at the Epi-Care Center for the past 12 years were evaluated and treated by a comprehensive team consisting of a neurologist, neurosurgeon, psychiatrist and neuropsychologist. The five suicides among this population represent a much lower fatality rate if compared with the population reported by Mendez and Doss (1992). This decreased rate may result from the ready availability of a psychiatrist for treatment of every patient with dysphoric disorder or psychosis.

There are limitations to suicide prevention, even if one is alerted to the risk. Of our patients who committed suicide, two were noncompliant with our treatment and two, for geographic reasons, were followed elsewhere prior to their suicide. In retrospect, our fifth patient, who had become dysphoric after control of his seizures by medication, should have been brought in for treatment upon the emergence of an episode of rage that preceded his suicidal act. In our experience, timely psycho-pharmacological treatment of the dysphoric disorder or of an interictal psychosis can usually prevent a suicidal outcome of the epileptic disorder.

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