Journal Article Annotations
2021, 3rd Quarter
Annotations by Liliya Gershengoren, MD, MPH and Sohail Mohammad, MD, MPH
In a retrospective study using Veterans Affairs Health System administrative data, chronic headache disorders were associated with an increased risk of suicide attempts among veterans. This risk was further elevated for women veterans with chronic headache. Concurrent traumatic brain injury increased the risk of suicide attempts especially in men.
Strength and weaknesses:
This longitudinal retrospective study examined a large cohort of veterans which is a particular strength. Another strength is obtaining physician verification of variables in question rather than relying solely on questionnaire-based surveys. One significant limitation is the lack of specificity concerning the duration and severity of chronic headache, traumatic brain injury, and mental health conditions. Chronicity does not always reflect the main characteristics of pain duration. In addition, an overwhelming majority of the patients in the study were identified as white and male, which limits generalizability to other, non-Veteran patient populations.
CL psychiatrists are often asked to comment on the psychiatric comorbidities of patients with chronic pain. This article highlights the implications of chronic headache disorders—with or without traumatic brain injury—on the risk of suicide attempts. Veterans are known to have higher suicide rates compared with the general population and require unique consideration when being evaluated.
In a meta-analysis of 17 randomized trials, 7of 4000 patients treated with antiseizure Medications (ASMs) (0.30%) had suicidal ideation, compared with 7 of 1996 patients treated with placebo (0.35%). There were no deaths by suicide. Overall, for the 5 ASMs in the study, there was no evidence of statistically significantly increased risk of suicidal ideation (risk ratio 0.75; 95% Confidence Interval: 0.35 to 1.60) or suicidal attempt (risk ratio 0.75; 95% Confidence Interval: 0.30 to 1.87). The 5 antiseizure medications reviewed were eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate.
Strength and weaknesses:
The meta-analyses included 7 studies that conducted structured evaluation of suicidality using the validated Columbia Suicidality Severity Rating Scale (C-SSRS). The study followed the Preferred Reporting Items for Systemic Review and Meta-analyses (PRISMA) reporting guideline. The study limitations include a description limited to 5 ASMs and lack of use of standardized suicidality questionnaires in nearly 60% of the study population. Of the patients who had structured evaluation of suicidality using C-SSRS, 56% were from studies on only 2 Anti-Seizure Medications (ASMs), i.e., eslicarbazepine and brivaracetam. The meta-analysis did not include ASMs that are commonly used as mood stabilizers in patients with psychiatric disorders.
It is important to be aware of the potential adverse events of ASMs and their association to suicidality. Anti-Seizure Medications (ASMs) are commonly used as mood stabilizers in patients with psychiatric disorders. A structured evaluation of suicidality pre- and post-trial of ASMs may need to be considered using the validated Columbia Suicidality Severity Rating Scale (C-SSRS). Consultation-liaison psychiatrists should collaborate with neurologists to weigh the ASMs benefits versus the risks and their association to suicidality and support patients in informed and shared decision making.