Veterans with seizures are at increased risk of death from suicide and suicidal behavior (SRB), according to study results published in Neurology: Clinical Practice.
Cohort studies have shown that epilepsy increases the risk of suicide and SRB, regardless of antiseizure drugs, even after successful epilepsy surgery. Patients with psychogenic non-epileptic seizures (PNES) face similar psychosocial challenges as people with epilepsy, but do not share a common neuropathology, and to date no studies have reported the rates of suicide and SRB associated with PNES.
The study researchers pulled the data of 801,734 veterans from a cohort study of veterans enrolled in the Veterans Health Administration from 2002 to 2017. They split them up based on diagnosis of PNES (n = 752), epilepsy (n = 10,994, and none (n = 789,988)), which they call the general group. People with PNES and epilepsy were excluded.
There were 1,870 suicide deaths in total: 0.80% of veterans with PNES, 0.65% of veterans with epilepsy, and 0.23% of veterans in the general group. SRB, as defined using the ICD-9 and ICD-10 coding, was present in 29% of the veterans with PNES, 24% with epilepsy, and 5.6% in the general group.
The standardized mortality rate (SMR) for PNES, epilepsy, and the general veteran group were 2.65 (95% CI, 1.95-5.52), 2.04 (95% CI, 1.60-2.55), and 0 , 7 (95% CI, 0.673-0.738)), respectively. More than 80% of epilepsy suicide deaths occurred 1 year after diagnosis.
Veterans diagnosed with PNES (relative risk [RR]1.75; 95% CI, 1.51-2.02) had a higher risk than veterans with epilepsy of dying from suicide and a 3.82 (95% CI, 3.32-4.39) times higher risk of suicide than general Group. Veterans with epilepsy were 2.19 times the risk of suicide compared to the general group (95% CI, 2.10-2.28).
Veterans with PNES were also at higher risk for SRB compared to veterans with epilepsy (RR, 1.61, 95% CI, 1.51-1.73) and the general population (RR, 3.65; 95% CI, 3rd grade) , 42-3.90), while veterans with epilepsy were more than 2.26 times more likely (95% CI, 2.22-2.31) to be involved in SRB than the general group (P <0.0001 for all) .
Female veterans with PNES died of suicide less than male veterans with PNES (RR 0.48; 95% CI 0.46-0.50; P <0.0001) or participated in SRB (RR 0.96; 95% CI 0.95-0.98); P <0.0001). Black veterans had an RR of 0.93 (95% CI, 0.92-0.94; P <0.0001) for SRB compared to white veterans with PNES.
Anxiety and traumatic brain injury were only significantly associated with SRB (P <0.0001). Of the comorbid covariates, veterans with PNES who engaged in substance abuse had the greatest risk of suicide with a RR of 1.92 (95% CI, 1.88-1.96; P <0.0001). Veterans with PNES who used psychotropic drugs were at the highest risk of engaging in SRB (RR 8.38; 95% CI 8.15-8.61; P <0.0001).
One of the limitations of the study is its limited generalizability, as the majority of the population were men between the ages of 30 and 49 years. In addition, patients were not systematically assessed and the confidence intervals are large due to the limited sample size.
Based on their findings, the study’s researchers concluded that “Veterans with PNES and veterans with epilepsy have a significantly increased risk of suicide and SRB compared to the general population.” They added, “Future research will investigate whether PTSD therapy and PNES-guided psychotherapy protect suicide and whether delayed diagnosis of PNES plays a role in increased suicidality.”
Disclosure: Some authors of the study stated links to the pharmaceutical industry. For a full list of the authors’ information, see the original reference.
Bornovski Y., Jackson-Shaheed E., Argraves S. et al. Suicide and seizures: a national cohort study of veterans. Neurol Clin Pract. Published online March 12, 2021. doi: 10.1212 / CPJ.0000000000001070