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Suicidal ideation and behavior have been associated with a variety of neurological illnesses. In this episode, Tatiana Falcone, MD discusses the importance of early screening, management and the use of therapeutics for suicidality in patients with neurological disorders.

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Suicidality in Individuals with Neurological Disorders

Podcast Transcript

Intro:  Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD:  Welcome to Neuro pathways. In today's episode, we address the crossroads of conditions that are too often related and still regarded with uncertainty and suspicion. That being suicide and neurologic disorders. I'm your host, Glen Stevens neurologist, neuro-oncologist in Cleveland Clinics Neurological Institute. I'm very pleased to have Dr. Tatiana Falcone join me for today's conversation. Dr. Falcone is a psychiatrist with Cleveland Clinics, Department of Psychiatry and Psychology and Epilepsy Center. She co-edited a textbook published in 2018 called Suicide Prevention, a practical guide for the practitioner with a chapter devoted to children and adults with epilepsy. Tatiana, welcome to neuro pathways.

Tatiana Falcone, MD:  Thank you.

Glen Stevens, DO, PhD:  So our first question, what is the prevalence of suicide in those living with neurological conditions?

Tatiana Falcone, MD:  The prevalence of suicide in patients with neurological conditions may be a little higher than in the general population. When you think about that, some of the explanations is because a lot of the patients with neurologic conditions have higher incidence of mood disorders. And when your mood disorder progresses, then the incidence of suicide increase. So depending on the study that you look at and what scale they're using is somewhere around 25 to 40%, and it is different from different conditions like for patients with epilepsy, some States have reported up to 50% for patients after a stroke, there are studies that report up to 22%. So it's different. According to how soon after the event happened, the patient is reporting this suicidal thoughts.

Glen Stevens, DO, PhD:  So the question that begs to answer is why the propensity for suicide in those living with neurological conditions, what is it about the condition?

Tatiana Falcone, MD:  So there's multiple reasons, so from the environmental factors, leaving when a chronic condition that affects your brain right? Can seriously impact your everyday life, right? Can impact your ability to sometimes sustain a job, your ability to maintain some of the regular things that you do in your quality of life may impact your everyday life. But also the brain. When you have an illness that is affecting your brain, it might be producing the neurologic symptoms that the patient might be having. But it also depression comes from the brain and whenever certain areas of the brain might be affected and might be higher incidence of depression, right?

The longer that someone has depression without being treated, then the more probability that they will have suicidal thoughts. And one of the things that we see in patients with neurologic conditions is sometimes people feel, maybe when my epilepsy is getting better, then I'm going to get better from these mood issues, or maybe when I start feeling better from the movement issues that I'm having, then the mood issues are going to get better. And what we know happens is they continue to progress. And unless you target both a neurologic condition, but also a mood disorder is not going to get better. And the longer that you have it, the more probability that you have suicidal thoughts and attempt suicide later on.

Glen Stevens, DO, PhD:  So COVID has been very difficult for everyone. Anecdotally, or if there's data out there, how was 2020 for this problem? Is it more, is it less, is it stayed the same?

Tatiana Falcone, MD:  I can tell you about our data in children, right? So in the last year, the Pediatric Department has been tracking a scale that we do in adolescence. It's called the PHQ-9 adolescence, nine questions. And in the last year they did 26,000 screenings yeah me and MyChart. And we track the incidence of suicidal thoughts by month. And this is not only neurologic conditions, but all the kids in the kids clinic, we saw that, especially around the time when we were having this stay at home order, we have the scores of the kids by month. And we saw that April was actually the highest month where kids were reporting suicidal thoughts. And then later on in the year, we saw that in September, the thoughts went back again. So if you think we see some correlation with several factors, I think one might be the stay at home order, inability to do regular activities,

The social piece, the inability to connect with your friends in kids, sports are huge. Inability to do your irregular extracurricular activities like theater, right? All the clubs that the kids have after school, and right now, we are in the process of looking at the issue of suicidal thoughts in kids with epilepsy during COVID, but we don't have the numbers yet. I can tell you that when we look at the numbers of how many kids with epilepsy who are never had a psychiatric disorder diagnosed before, we asked the question about, are you having any thoughts about suicide? the answer is really high. And before we were targeting only those kids who have depression, but there were some guidelines by the American Epilepsy Society, that said that we should be screening everybody. And so we started doing that and we found like the incidents in this population that kids with epilepsy was high and surprisingly high for people who were not reporting depressive symptoms. And yet the other important point is they are not going to tell you unless you ask them.

Glen Stevens, DO, PhD:  So let's just pivot for a second and talk about your role in support of patients with neurological conditions. What approach do you take for screening for suicide?

Tatiana Falcone, MD:  What we decided to a couple of years ago, was that psychiatric conditions were common in patients with epilepsy. So we added several scales to a regular armamentarium of scales that we sent in the regular basis when they come to see the epileptologist. So we have two scales from depression. One that it was two questions, the PHQ-2, and one that it was 16 questions the CES-D. So if the patient was positive in the PHQ-2, then they received a full 16 questions for the CES-D if the patient was positive for the CES-D then, they received the Ask (ASQ) that is a four questions. And we were stopping and doing the Ask only in psychiatry. But then we saw that this is a huge need and, we're seeing more than 200 patients a year on the Peds Epilepsy Center. And it's really hard for me to see everybody, right?

So what we did is like this could be done at the general level. The epileptologist can be sending this and this is the scale is going to track what patients are having these thoughts. So whenever the epileptologist is opening the chart and he seen that the patient said yes to these questions, then they have to assess in that moment, who is patient is currently having these thoughts right now? Or is it more like depression? Right? And if we feel like the patient needs any extra attention, then they can contact the social worker and they can come and do a further evaluation. Or if the patient is saying, I have a plan, then we are sending the patients to emergency room.

So you think, Oh, we're sending a lot of patients. No, it was really interesting to see that from everybody that we saw, let’s say, after you ask the second question, is this something that you're thinking right now, or this is something that you thought six months ago that takes 50% of the sample out. Most of the people say, yeah six months ago I was feeling really bad, but now things are a little better. So we can sometimes it's a scale of follow-up appointment and see how they are. But in the study that we presented The American Epilepsy Society, we end up sending like around 13 people out of a 100 to the emergency room.

Glen Stevens, DO, PhD:  Well, I can tell you that in neuro-oncology, we started doing PHQ9s on our patients. And if they score it over a certain level or they checked suicidality, the ninth question, then they automatically saw the social worker. And then our social worker would then be the portal to either see a psychiatrist or to go to the emergency department at that point in time. So that's how we handled it. But for those of us medical professionals who may be less comfortable addressing a patient about suicide, any tips that you can share?

Tatiana Falcone, MD:  Yeah. So your patient trusts you, right? They trust you with their care. They are coming to see you because they believe that you can help them. Is really hard for the patient to bring this up. They're not going to bring it up unless you ask them. So I think the most important thing is knowing that you can ask a couple of simple easy questions, right? And if the patients say yes to any of them, then we just have to follow up. Right if they said, yes, I'm having these thoughts, then we have to be a little more specific.

We want to say okay, is this something that happened a month ago or has it happened in the last week? If they said, "yeah, I've been having these thoughts in the last week", then we have to say, okay, let us know how much time of your day you're spending on these thoughts. And we know people who are spending more than five hours a day on these thoughts are a higher risk. So trying to track how much time. And then the intensity is also important. So if one is like your opinion is likely to do anything like this, and five is like, you thought about it and you almost did it yesterday? Where are you on that scale right now from one to five? And I think that give you a really good idea where the patient is.

Glen Stevens, DO, PhD:  How do you address patients with varying degrees of suicide risk and what tools do you leverage to manage them?

Tatiana Falcone, MD:  We ask this question to everybody, and then we assess how severe the suicidal ideation is. Then when we think that suicidal ideation might be severe or some people might have chronic, severe suicidal ideation. So then we have to see what is the risk today. And then we ask, when you have these thoughts do you have a plan, right? And if they said that yes they had a plan, what is their plan? So how much further, if they look on the internet, which one of the medications that they're taking, are they more little ones they look or, what other methods people use to hurt themselves?

Right? Or did they took any steps? Some people say I put the medications in the palm of my hand and then I decide against it. Right, so when we are that point that the patient has aborted attempts. I think we know the risk is higher. And the last question is right now, what is the likelihood that you're going to act on those thoughts? Think the patient said yes like I have been really thinking about it and I don't know if I can be safe. Then I think, that these patients might need to go to the hospital.

Glen Stevens, DO, PhD:  So what role do medications and therapeutics have in the treatment of suicide?

Tatiana Falcone, MD:  So there are the effective treatment for mood disorders. And we know that when your mood disorder gets better then the suicidal thoughts get better. And the medications are effective, but they might take up to four to six weeks. So therapy is key because you are giving the patient hope and also tools to manage those suicidal thoughts. But when they come back, they know what to do.

Glen Stevens, DO, PhD:  So are there any medications that would treat mood disorder that could negatively affect epilepsy that you would like to comment on?

Tatiana Falcone, MD:  Yeah. In epilepsy, there's one medication that we don't use because we know it can increase your probability to have seizures. So we avoid Bupropion in patients with epilepsy.

Glen Stevens, DO, PhD:  And what about your use of Ketamine? Are you using ketamine for suicide ideation?

Tatiana Falcone, MD:  So it's funny you ask, we are just about to start doing a study that is going to be four years where we going to be evaluating the use of Ketamine in patients after they attempted suicide. So there are 156 studies about this. From those, there are four studies in other lessons, in their lessons none of them have evaluated the effect on the suicidality. So this is going to be one of the first studies who's going to evaluate the effectiveness of Ketamine for the treatment of suicidal thoughts in youth.

Glen Stevens, DO, PhD:  So Tatiana I'm a neuro-oncologist, I look after brain tumor patients, and a lot of our patients have seizures. As you know, the FDA came out with a warning that patients that take anti-epileptic medications have a small but increased risk of suicide thought or behavior. And one of the concerns associated with this is that a patient's heard this, that they would not want to take their seizure medication. And obviously it's very important for us to have patients take their seizure medications. So when patients ask me about this conflict, how should I answer that for them?

Tatiana Falcone, MD:  So I will say, thank you so much for bringing this to me. I think it's very important that you're aware of anything that is happening, anything new affect when you're taking any medication. What happened with those initial studies was when they look at the rate of suicidal thoughts in patients with epilepsy, they did not control for the incidence or the severity of depression. And we know that patients with epilepsy might have a higher incidence of depression. So that might be the reason why when you have the same dose for a longer time and you untreated you just might develop suicidal thoughts. But nonetheless it is true that some medications can have effects on your mood so if you notice that after you recently start a medication your mood is changing, or you are getting more loud or irritable, this is a very important thought to communicate to your doctor because there are things that we can do to help you.

Glen Stevens, DO, PhD:  Any differences in managing the pediatric population versus the adult population for suicidal ideation.

Tatiana Falcone, MD:  We did a study recently that was published on Epilepsia in December, looking at the conversations that adults with epilepsy have about suicide versus children with epilepsy. And one of the things that we saw is there are two different stages in the adult population. We saw a lot of hopelessness, the impact on their ability to work and things was one of the journeys to get there to have suicidal thoughts. In kids, it was the unknown, unlike most of their comments related to suicide. And that being on trying to understand how people were coping with their epilepsy. So they were asking for help and they were trying to understand whether it would do to make it better. So I think, one of the most important things to address in youth is like sometimes parents trying to protect their kids, not including them in the regular conversations about their care,

And it's very important because when you don't, they get more worried about what's happening. So for kids, I will say including them in the conversations about their care at their level, so they understand what's happening and giving them kind of a timeline so they understand what's happening. And In adults we saw the hopelessness was something major. So trying to make sure that every time that someone leaves your office after an appointment, they have hope. So you don't want to finish your appointment when someone is crying and feeling really bad about what's going on right now, you have to try to make sure that they understand what other possibilities do we have and where do we go from here? They can be helpful.

Glen Stevens, DO, PhD:  Well Tatiana I want to thank you for joining me today. This has been very insightful conversation and I appreciate all your time.

Tatiana Falcone, MD:  Thank you so much for inviting me.

Outro:  This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, ClevelandClinic.org/neuropodcast or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word and thank you for listening.

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Neuro Pathways

A Cleveland Clinic podcast for medical professionals exploring the latest research discoveries and clinical advances in the fields of neurology and neurosurgery. Learn how the landscape for treating conditions of the brain, spine and nervous system is changing from experts in Cleveland Clinic's Neurological Institute.

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