Massimiliano Beghi

Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review

Objectives This review aimed to identify the evidence for predictors of repetition of suicide attempts, and more specifically for subsequent completed suicide. Methods We conducted a literature search of PubMed and Embase between January 1, 1991 and December 31, 2009, and we excluded studies investigating only special populations (eg, male and female only, children and adolescents, elderly, a specific psychiatric disorder) and studies with sample size fewer than 50 patients. Results The strongest predictor of a repeated attempt is a previous attempt, followed by being a victim of sexual abuse, poor global functioning, having a psychiatric disorder, being on psychiatric treatment, depression, anxiety, and alcohol abuse or dependence. For other variables examined (Caucasian ethnicity, having a criminal record, having any mood disorders, bad family environment, and impulsivity) there are indications for a putative correlation as well. For completed suicide, the strongest predictors are older age, suicide ideation, and history of suicide attempt. Living alone, male sex, and alcohol abuse are weakly predictive with a positive correlation (but sustained by very scarce data) for poor impulsivity and a somatic diagnosis. Conclusion It is difficult to find predictors for repetition of nonfatal suicide attempts, and even more difficult to identify predictors of completed suicide. Suicide ideation and alcohol or substance abuse/dependence, which are, along with depression, the most consistent predictors for initial nonfatal attempt and suicide, are not consistently reported to be very strong predictors for nonfatal repetition.

Correlation between cognition and behavior in epilepsy.

Summary:  Cognitive function is more frequently impaired in people with epilepsy than in the general population, and the degree of cognitive impairment varies according to the epilepsy syndrome. Behavioral disorders are also more frequent in people with epilepsy than in individuals who do not have epilepsy. Behavioral disturbance is observed more frequently in people with drug‐resistant epilepsy, frequent seizures, and/or associated neurological or mental abnormalities. In children and adolescents, many data suggest a close link between behavior/cognition and some specific epilepsy syndromes. For example, aspects of mood, behavior, personality, and cognition may be related to temporal lobe epilepsy or juvenile myoclonic epilepsy. Behavioral disorders may precede, occur with, or follow a diagnosis of epilepsy; they differ between children and adults. Predictors of behavioral disorders in children with epilepsy are the epilepsy itself, treatment, the underlying lesion, and personal reactions to epilepsy. More specifically, conditions in which behavioral disorders may be associated with epilepsy include depression, psychosis, particular personality traits, aggression, anxiety, and attention deficit and hyperactivity disorder.

Risk factors for fatal and nonfatal repetition of suicide attempt: A critical appraisal.

Purpose of review To perform a critical appraisal of reports on suicide attempts published in 2009, looking for features and predictors of suicidal behavior. Recent findings We searched Psychinfo, Embase, and Pubmed in the period from 1 December 2008 to 31 December 2009 looking for papers on suicide attempt. Rates of suicide attempts are in line with previous data and confirm a north–south gradient in the suicide attempt rate. Previous attempts are the strongest risk factors for further attempt. Moreover, we point out the importance of mood disorders (in particular depression) and personality disorders, unemployment, and a medium age as risk factors. In adolescence, the repetition rate seems to overlap that of the adult population, though the samples are very small. Even in this case, the presence of a previous suicide attempt increases the risk for repeated suicide attempt. By contrast, the role of psychiatric and demographic variables is less clear. Studies on personality disorders confirm that having a personality disorder increases the risk for further attempt, but this correlation is significantly less strong for fatal repetition. In depressed patients, the presence of anxiety perhaps acts as a protective factor. Summary The risk for a suicide attempt is higher for people who had previously attempted. Having a psychiatric diagnosis and more specifically a mood disorder is also a strong predictor for both fatal and nonfatal suicide attempt.

Idiopathic Generalized Epilepsies of Adolescence

Summary:  The prevalence of idiopathic generalized epilepsies (IGEs) has been assessed as being 15–20% of all epilepsies. The seizure types in IGEs are typical absences, myoclonic jerks, and generalized tonic–clonic seizures (TCS), alone or in varying combinations and with variable severity. The seizures tend to be more frequent on awakening and with sleep deprivation. This group of clinical conditions includes among others, age‐related epilepsy syndromes of adolescence such as juvenile absence epilepsy (JAE), juvenile myoclonic epilepsy (JME), and IGE with generalized TCS or epilepsy with grand mal on awakening (EGMA). The classification of IGEs follows two schools of thought; one maintains that IGEs are a group of different and separate syndromes while the other suggests that IGEs are one biological continuum. Patients with IGEs may have mild impairment of cognitive functions, especially verbal memory and other frontal lobe functions, despite a normal IQ, and some seem to have characteristic personality traits, although further studies are needed to support this theory. They appear to lack a degree of self‐control, to neglect their physical needs, and are poorly compliant with therapy. Some patients become obstinate and are impressionable. The cognitive and behavioral aspects of these patients suggest an involvement of frontal lobes.

Learning Disorders in Epilepsy

Summary:  Learning disorders (LD) are disorders interfering with academic performance or with daily living activities requiring reading, writing, or mathematical abilities in subjects with a normal intelligence quotient. The prevalence of LD in the general population has been found to be 2–10% and reading disorders are the most frequent subtype. Epilepsy is one of the commonest neurological disorders in childhood with an estimated prevalence in 4–5/1,000. Epilepsy is considered to be idiopathic or cryptogenic in approximately two‐thirds of cases. LD are more common in people with epilepsy than in the general population: about 25% of patients with epilepsy are said to have LD. Various psychosocial, medication‐related, and epilepsy‐related factors may be associated with LD in epilepsy. LD can be either permanent or state‐dependent. Permanent LD are caused by a brain lesion and/or a stable brain dysfunction. In contrast, state‐dependent LD are potentially reversible and treatable; they are caused by epilepsy‐related factors. If allowed to persist for a long period, a state‐dependent LD may become permanent.

A Review of the Costs of Managing Childhood Epilepsy

Epilepsy is a chronic treatable condition for which new diagnostic tools and several new drugs and non-pharmacological treatments are now available. The cost profile of these options is assessed here through an overview of the available literature focusing on studies of childhood epilepsy.Several methodological problems arise when interpreting the results of economic studies in epilepsy, including the variability of the study population and costs items, the reliability of the sources of cost, the limitations of the methods of data collection and the deficiencies of the study designs, with reference to the measures of treatment benefits. International comparisons are then difficult because economic results cannot be compared on account of differences in monetary issues, clinical practice patterns and healthcare system frameworks.The economic aspects of epilepsy are different in children and adults. Differences are detectable in the incidence and expression of epileptic syndromes, social and emotional impact, availability of antiepileptic drugs, hospital admissions, diagnostic tests and referral to specialists, social assistants and other healthcare professionals. In addition, children have access to medical services only with the help of a caregiver, for whom there may be lost work days or under-employment.The mean annual cost per child with epilepsy was

Epilepsy and family expressed emotion: results of a prospective study

US1853 for controlled epilepsy and

Utilization and Costs of Antiepileptic Drugs in the Elderly Still an Unsolved Issue

US4950 for uncontrolled epilepsy in a Spanish study performed in 1998 and the annual direct costs per child with epilepsy ranged from €844 for patients in remission to €3268 for patients with drug-resistant epilepsy in an Italian study done between 1996 and 1998. The Spanish study showed that direct costs are the major source of expenditure for children with epilepsy.These studies along with a number of other cost-of-illness studies in combined populations of adults and children showed that service use and costs increase with more severe forms of illness and seizure frequency, this being more marked in adults than in children. Moderate cost differences may be expected between children (higher) and adults (lower), particularly with reference to initial investigations. Costs of epilepsy are mostly explained by hospital admissions and drugs; in particular, drug costs tend to dominate in more well controlled epilepsy, while both hospital admissions and drugs are significant costs in less well controlled epilepsy. Newly diagnosed patients can incur significant hospital and diagnostic costs. Costs for epilepsy tend to be lower for patients cared for in general practice or outpatient settings than in hospital settings. Seizure control by drugs, ketogenic diet or surgery is associated with a significant reduction in the costs of epilepsy.

Psychogenic non-epileptic seizures: so-called psychiatric comorbidity and underlying defense mechanisms

PURPOSE To verify the emotional components expressed by the relatives of adult patients with a diagnosis of epilepsy, and whether they are related to adjustment to the illness and the course of the illness over time. METHODS We studied a consecutive sample of 43 outpatients suffering from epilepsy and 43 key relatives using the Camberwell Family Interview (CFI), with the expressed emotion (EE) of the relatives being rated at baseline (T0). EE refers to a construct representing some key aspects of interpersonal relationships: the relatives were assigned to the high-EE group if they scored 3 or more on the emotional over involvement (EOI) scale, or showed hostility, or made 6 or more critical comments. The patients were clinically evaluated at baseline and for 1 year of appropriate treatment by an epileptologist who was blinded to the EE ratings. They also completed STAI XI, STAI X2 and Becks Depression Inventory at baseline. RESULTS Twenty-six relatives (60%) were rated as showing a high degree of EE. In the 12-month follow-up study, high EE and high EOI were found to be associated with a significantly higher seizure frequency than that recorded for the patients living in low-EE households (p<0.05). The patients from households assessed as reflecting a high degree of criticism showed poor drug compliance (p<0.01), whereas those with relatives assessed as having a high degree of warmth showed better clinical and pharmacological compliance (p<0.01). High family criticism scores also correlated with higher study entry levels of depression (p<0.05) and trait and state anxiety (p<0.05) among the patients. CONCLUSIONS The study findings highlight the impact of particular components of the family emotional climate on the clinical course and psychological adjustment of patients with epilepsy.

Validation of a novel classification model of psychogenic nonepileptic seizures by video-EEG analysis and a machine learning approach.

The aging of the general population in industrialized countries has brought to public attention the increasing incidence of age- and aging-related clinical conditions. Management of multiple and chronic disorders has become a more important issue for healthcare authorities because of increasing requests for medical assistance, the greater numbers of drugs required and drug interactions reported, and the increase in treatment-related costs.Epilepsy is a chronic clinical condition affecting both sexes and all ages with a worldwide distribution. The incidence of epilepsy, after childhood, increases with age and the cumulative risk of epilepsy by 80 years of age ranges from 1.3% to 4% in different study populations. Although the issues for people with epilepsy are similar for older and younger adults, the elderly may require more attention with regard to selection of antiepileptic drugs (AEDs) than younger patients. Elderly patients with newly diagnosed epilepsy are more likely to remain seizure-free on AED therapy than younger populations; however, the toxicity of AEDs in elderly patients is ill-defined because seizures may be difficult to recognize in this group and the symptoms and signs of toxicity can be attributed to other causes. Moreover, elderly people have chronic clinical conditions and are more likely to be taking medications that could possibly interfere with AEDs.Some older AEDs such as phenobarbital and phenytoin should not be used in the elderly because of their pharmacokinetic and pharmacodynamic profiles. There is no evidence that new AEDs, despite their better tolerability profiles, are advantageous in terms of attaining freedom from seizures compared with older agents.Older AEDs are much less expensive than the new compounds and, with some exceptions, appear to be more cost effective. New AEDs may be cost effective only in patients who are not able to tolerate or who are resistant to older compounds or when the use of an older drug is contraindicated. However, there are no cost-effectiveness studies in the elderly and further evidence is needed to confirm these assumptions.