Depression and Suicide Among Patients With Epilepsy

Psychiatric comorbidities, especially depression and suicidality, are strongly associated with epilepsy. The lifetime prevalence of depression is estimated to be 10% in the general population; however, among patients with epilepsy, the prevalence is as high as 25% (1). Persons with epilepsy also have a higher risk of suicide, and one population-based analysis showed that the rate of suicide was 3.5–5.8 times greater among those with epilepsy, compared with the general population (2). This finding demonstrates the importance of screening patients with epilepsy for depression and suicidality and supports the psychiatrist’s role in the care of these patients. The association between epilepsy, depression, and suicidality is discussed below in regard to antiepileptic drug (AED) adherence, epilepsy surgery, and psychosocial factors postsurgery.

Among patients with epilepsy who are taking AEDs, the most common reason for seizures is related to AED nonadherence. In individuals with depression or other mood disorders, cognitive function, including attention and memory, may be disturbed, which can interfere with AED adherence. An increased seizure burden can contribute to poor quality of life and significant disability, perpetuating the cycle of depression and seizures. Psychiatric care can assist these patients by treating the underlying or emerging depression and providing interventions aimed at improving AED adherence.

Some patients with epilepsy that is AED-refractory may be candidates for surgical intervention, which can be an effective treatment in reducing seizure burden. However, these patients are at high risk of postsurgical psychiatric disturbances, including development of new psychiatric conditions or exacerbation of pre-existing ones (3). Most commonly, patients develop depression or anxiety, which may interfere with perisurgical care. For example, they may not attend follow-up appointments or may be poorly adherent to maintenance AEDs, which may be required in some cases because surgery is not always curative. One study has shown that proper psychiatric evaluation and treatment of patients with epilepsy can improve postsurgical outcomes (4).

One important concept to discuss with patients undergoing presurgical workup is the "burden of normality" described by Wilson et al. (5). As patients go from a state of chronic illness to being "cured," they experience a shift in various psychosocial demands. This may increase their risk of developing a psychiatric disorder, particularly an affective disorder, if they do not possess the appropriate coping skills to deal with those changes. Psychiatric care can assist in the transition from a state of disability to that of normalcy through interventions such as supportive psychotherapy or cognitive-behavioral therapy. Psychotherapeutic intervention can assist the patient in developing coping skills and insight regarding interpersonal and role changes.

The current standard of care for patients with epilepsy is typically led by a neurologist. However, because of the prevalence of comorbid psychiatric disorders, it would be most appropriately managed by an interprofessional care team, including psychiatry, to address all aspects of the biopsychosocial model. Improved awareness among neurologists and psychiatrists of psychiatric comorbidities in epilepsy and provision of specialty care by both professions will benefit patients with epilepsy and optimize patient outcomes.