Death in epilepsy With special
attention to suicide cases
|
Toshihiko Fukuchi MD*1 |
*1: Fukuchi Clinic *2: Aichi Medical University, Neuropsychiatry Department *3: National Neuropsychiatry Center, Musashi *4: Shizuoka Prefectural Mental Health Center *5: Utano National Hospital |
KEY WORDS: Suicide, Mortality, Temporal Lobe Epilepsy, Postictal Psychosis Abstract
Purpose: To examine clinical features of cases of death among epilepsy patients as a case control study, with special attention to suicide.
Methods: We analyzed the records of 43 deceased patients with well-classified epilepsy from 2 epilepsy centers in Japan. Those who died from a direct sequel to the underlying disease such as brain neoplasm were excluded. The subjects were compared with 1722 control patients of the Kansai Regional Epilepsy Center who showed definite subtypes of epilepsy.
Results: Among the major causes of death, 13 of the subjects suffered accidents (mostly drowning), 10 experienced sudden unexpected death, 7 had status epilepticus, and 6 committed suicide. There were no significant differences with regard to clinical variables except for psychotic episodes, which were more frequently encountered in subjects than in controls (chi square=6.771, p=0.009, Yates' modification). Statistically significant differences were found by epilepsy type as well (chi square=14.72, p=0.002), with temporal lobe epilepsy (TLE) proving to be most closely associated with death among the epilepsy patients. Further, suicide was only encountered in patients with TLE and the association was statistically significant (chi squre=5.119, p=0.024). Half of those who committed suicide (n=3), did so by jumping in front of an oncoming train while in the midst of an episode of postictal psychosis.
Conclusion: Most cases of suicide in patients with epilepsy were found to be the result of an immediate causal relationship with ictal or interictal epileptic manifestations, rather than a result of augmentation of psychosocial stressors generated by a long-standing handicap derived from the severe illness.Introduction
Death as a direct sequel to convulsive disorders remains a major cause of mortality in people with epilepsy in developing countries (Senanayake & Peiris,1995), whereas, in Western countries, the rate has been declining steeply and steadily since the 1950s, especially among children (Ocallaghan et al.,2000). While appropriate antiepileptic medication and compliance can prevent death due to status epilepticus or injuries associated with seizures in most cases, outcomes such as suicide and sudden unexpected death are still difficult to prevent. Sudden unexpected death has been studied intensively (Nilsson et al.,2001; Tomson,2000; Langan et al.,2000; Donner et al.,2001; Walczak et al.,2001; Nashef & Brown,1996), however, case control studies of suicide among an epileptic population are scarce. In this study, we examined cases of death among epileptic patients, with special attention given to suicide.
Subjects and Methods
We reviewed the case records of all outpatients of the Kansai Regional Epilepsy Center (n=27) and National Neuropsychiatry Center (n=19) who were known to have had epilepsy and died from 1984 to 1994 and 1991 to 1998, respectively. From these, we excluded those who had unclassified epilepsy or who died of direct sequel to the underlying disease such as a malignant neoplasm. Forty-three patients were studied as subjects in the present study. Clinical data such as sex, age at epilepsy onset, age at death, and type of epilepsy were considered. As a control group, we used the records of other outpatients with epilepsy who had visited Kansai Regional Epilepsy Center from 1984 to 1994, except for those diagnosed with unclassified epilepsy (n=1722). Epilepsy and seizure classifications were based on the definitions proposed by the International League against Epilepsy (Commission on Classification and Terminlogy of the International League Against Epilepsy, 1981;1989).
Statistical analyses were made with chi-square tests, using Yates' modification for small numbers.Results
1) Causes of death (Table 1) Accidents, including drowning and head trauma, as a result of seizures were the most frequently encountered causes of death in our .series. Among them, drowning in a bathtub stood out (n=11). Sudden unexpected death was the second most frequent cause of death, while suicide and status epilepticus were the reason in one seventh and one sixth, respectively, of patients who died during the observation period.
2) Subjects (Table 2) There were no significant differences between the subjects and controls with regard to clinical features, except for psychotic episodes, which were more frequently encountered in the subjects than in the control group (chi square=6.771, p=0.009, Yates' modification).
3) Epilepsy Types (Table 3) Statistically significant differences were found as a function of epilepsy type (chi square=14.72, p=0.002) and temporal lobe epilepsy (TLE) proved to be most closely associated with death among the patients with epilepsy.
4) Suicide (Table 4) In our series, suicide was only encountered in patients with TLE, and the association between suicide and TLE was statistically significant (chi squre=5.119, p=0.024). There were twice as many male patients (n=4) as female (n=2) in the suicide group. Further, it was noteworthy that half of these patients (n=3) killed themselves by jumping in front of an oncoming train in the midst of an episode of postictal psychosis.Discussion
Our results demonstrated that accidents (mostly drowning), sudden unexpected death, suicide, and status epilepticus were the 4 major causes of death among people with epilepsy. Our findings can not be applied without limitation, as the data originated from highly specialized epilepsy centers, however, because the population analyzed here is very large (more than 4000 subjects in total), we consider that the results reflect a general tendency in people with severe chronic epilepsy.
Previous studies have repeatedly suggested a heightened risk of suicide or suicide attempts among epileptic patients (Hawton et al.,1980; Matthews & Barabas,1981; Barraclough, 1987; Leviton et al.,1990; Mendez & Doss,1992). Further, most authors, including us, agree that the risk is particularly high in patients with TLE (Barraclough,1987; Mendez & Doss,1992). As noted by Hawton et al. (1980), we found a male preponderance as well. However, there remains a difference of opinion regarding whether TLE provides specific causative factors for self-destructive behavior or only promotes a general susceptibility to suicide. A prevailing view has been that TLE provides a greater degree of practical handicap to patients, which augments the risk for attempted suicide, just as in other chronic, intractable diseases (Barraclogh,1987; Harris & Barraclough,1997). However, several noteworthy studies have contradicted this, including Mendez and his colleagues (1989) who investigated possible causative factors for the high epileptic suicide rate by reviewing the cases of 22 patients with epilepsy chosen from 711 hospitalized for a suicide attempt. They found that patients with epilepsy had more psychotic disturbances and fewer adjustment disorders, and concluded that suicide attempts in epileptics were primarily associated with interictal psychopathologic factors, such as psychosis, rather than with psychosocial stressors. In the current study as well, which used other patients with epilepsy as control subjects, there proved to be a significant difference between the groups with regard to psychosis among various clinical variables.
Several other reports including ours (Kanemoto et al.,1999; Gerard & Spitz,1998) have pointed out that some patients become extremely prone to well-directed violent behavior following complex partial seizures. In a previous report (Kanemoto et al.,1999), we found that this violence toward the surrounding environment could be turned into a self-destructive impulse, which may eventually culminate in a furious suicidal attempt such as jumping in front of an oncoming train. According to Mendez and Doss (1992), who surveyed the records of 1611 epileptic patients seen in their neurology clinic during an 8-year period, 4 patients died by suicide and all of them had demonstrated partial complex seizures and temporal lobe foci. It should be noted that 2 of those 4 killed themselves during a brief psychotic episode associated with increasing epileptiform discharges or during a flurry of partial complex seizures. Their observations agreed very well with ours in the current series, in that suicidal attempts were found to occur during postictal psychotic episodes among 3 of the 6 patients in our study who had partial complex partial seizures and also died by suicide. As Brugger et al. pointed out (1994), periictal or postictal psychotic episodes in patients with epilepsy have long been known as risk factors for suicide. They also pointed out that paroxysmal heautoscopic episodes, epilepsy, and suicide were even regarded as a clinical triad. Since mental diplopia, or double consciousness, originally suggested by John Hughlings Jackson (1931), is a hallmark of postictal psychotic states (Kanemoto et al.,1996), this clinical association is also worthy of further amplification.
In conclusion, we considered that most suicide cases in people with epilepsy were the result of an immediate causal relationship with ictal or interictal epileptic manifestations, rather than a result of augmentation of psychosocial stressors generated by long-standing severe illness.References
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