The study employed a single-case design to investigate the interplay between epilepsy, antiepileptic drug usage, and suicidal ideation. A patient with epilepsy who developed suicidal thoughts following AED therapy was selected. Data collection encompassed a comprehensive review of medical history, psychiatric evaluations, neuropsychological testing, EEG and neuroimaging analyses, and semi-structured interviews with the patient and their family. Both qualitative and quantitative analytical methods were utilized to correlate clinical findings with existing literature, aiming to identify risk factors and inform effective management strategies. This study aims to draw attention to the diverse approaches to managing behavioral alterations in these patients through the presentation of a clinical case, considering factors such as the multiplicity of possible irritating brain foci, the diversification of neuronal functionality, and pharmacological iatrogenics.
Clinical Case
A 43-year-old man with a history of multiple unreported minor head injuries from football began neurological follow-up after presenting with partial-onset seizures and episodes that included absence seizures. Given symptoms indicative of posttraumatic epilepsy and the frequency of convulsive crises impacting his functionality, the patient was prescribed eslicarbazepine, titrated to 800 mg.
After four months on this medication, the patient was brought to the emergency department by his wife and referred to psychiatry due to suicidal ideation. The patient’s medical history was significant only for posttraumatic epilepsy diagnosed four months prior. Eslicarbazepine 800 mg was the only medication he had been using. No previous documented psychiatric evaluations were found. His wife reported a change in behavior over the past four months, characterized by social isolation, anorexia, irritability, and frequent marital conflicts, culminating in daily arguments over the past month and affecting his work performance as a textile merchandiser. The day before, he had expressed suicidal thoughts to a coworker, who alerted his wife. In the emergency department, the patient exhibited laconic speech and deferred to his wife for reporting events. A non-contrast computerized tomography (CT) scan of the head and neck performed a week earlier was unremarkable for acute fracture, intracranial hemorrhage, or edema; the electroencephalogram (EEG) demonstrated greater temporal slowing and sharp waves in the right temporal region. On mental status examination, the patient expressed suicidal ideation with a structured plan (intending to hang himself from a tree near his house with access to a rope), displayed affective flattening, and lacked emotional mobility. No psychotic symptoms were noted.
Given the clinical presentation, the patient was voluntarily admitted to the psychiatric service for evaluation and stabilization. The patient denied consuming illicit substances and alcohol, only mentioning smoking tobacco (about 10 cigarettes per day). Admission biochemical parameters, including complete blood count, ionogram, liver, kidney and thyroid function tests, and routine urine analysis, were unremarkable.
During psychiatric ward admission and prior to the introduction of psychopharmacology, a thorough evaluation with a detailed assessment over the past six months was conducted due to the absence of prior psychiatric or family history and no evidence of precipitating factors. This evaluation revealed that the onset of symptoms coincided with the introduction of the antiepileptic medication. At this stage, despite the suspicion of possible iatrogenicity from eslicarbazepine, the authors decided to maintain the medication at the 800 mg dosage. Collaboration with the neurology department was requested, and treatment with mirtazapine was initiated, titrated up to 30 mg. Additionally, diazepam 10 mg twice daily was prescribed to manage anxiety symptoms. On the third day of hospitalization, the patient still exhibited structured suicidal ideation, albeit with reduced underlying irritability and anxiety. At this juncture, he was assessed by the Neurology team, which supported the possibility of this being a side effect of eslicarbazepine. It was decided to switch the medication to topiramate, titrating up to 100 mg, with the rationale of its indication in this epileptic case and evidence of its low absolute risk. On the tenth day of hospitalization, with an improvement in mood and a reduction in the intensity of suicidal ideation, coupled with the patient expressing regret for his actions, and considering the supportive family environment and the patient’s own willingness, he was discharged with an outpatient follow-up appointment scheduled with Psychiatry, being at this point medicated with mirtazapine 30 mg daily, diazepam 5 mg twice daily, and topiramate 100 mg daily.
The patient continued to undergo psychiatric assessments every two weeks for the two months following discharge, with continued positive progression, reduction in suicidal ideation, and a euthymic mood with affective resonance. During this period, the patient had already discontinued diazepam and remained on mirtazapine 30 mg and topiramate 100 mg. Given the favorable progression, psychiatric assessments were spaced out to one month, and the patient remained psychopathologically stable six months after discharge. After the ninth month of treatment, considering the stability and moderate weight gain (approximately 8%), it was decided to begin reducing the mirtazapine dose and suspending it in the eleventh month of treatment. At the last reassessment appointment, eighteen months after hospitalization, the patient maintained psychopathological stability, being medicated only with topiramate 100 mg (maintaining follow-up in Neurology consultations, with stability of the epileptic condition).