AEDs, the FDA, and Suicide: Effects on Neurology Practice

March 30, 2009

Most epileptologists have a strong sense that AEDs are not a homogeneous group, readily lumped into a class for side effect evaluation purposes.

In January 2008, rather out of the blue, the FDA issued an alert about suicide and AED (antiepileptic drug) use. Later, the agency issued a requirement that manufacturers incorporate a warning into product labeling. Finally, they issued a public health advisory in December 2008. Epileptologists had significant concerns about the nature and analysis of the data set, aggregation of studies with heterogeneous treatment indications, the apparent disconnect between the FDA results and clinical consensus, as well as a variety of other matters. Most epileptologists have a strong sense that AEDs are not a homogeneous group, readily lumped into a class for side effect evaluation purposes. This debate continues.

But, what this discussion also brought out (again) was evidence of a certain lack of awareness about depression and suicide risk in epilepsy patients. As the experts in epilepsy treatment, neurologists and, especially, epileptologists should be cognizant of important comorbidities and address them. But screening for depression is less than optimal in neurology practice. To what degree, however, was not so clear.

The recent survey by Shneker adds a bit more data. They crafted a 21 question, on-line survey, and invited participation by e-mail. The survey asked about responses to the FDA announcement, and methods used by practices to identify and treat depression and suicidality in epilepsy. The response rate was 22% (even with multiple reminders). (Requisite disclosure: I was one of those who responded.) Most who responded were epileptologists in academic settings, with 74% reporting being part of a comprehensive epilepsy program. The results were interesting: Even in this highly epilepsy aware group, most did not warn about suicidality when beginning an AED, and most did not use a numeric depression screen. Half indicated their practices would not be affected by the FDA alerts. Notably, 41% recalled patients who had attempted suicide.

Limitations include the low response rate. Probably more problematic is selection bias: Participants were identified through the American Epilepsy Society, and thus have an above average degree of interest in epilepsy. This group likely is more aware of comorbidities such as depression, and probably asks about depression and suicidality more often than non-members. All that said, this survey and others highlight that screening for depression in epilepsy in neurologic practices is inadequate. And, I find this most unfortunate given the close association between neurology and psychiatry.

Clear conclusions emerge: Depression is more common in persons with epilepsy than the general population. Suicide is as well. At least some antiepileptic drugs increase suicide risk. And, we need to be screening for depression and suicide risk factors much more often and effectively than we do now.