Suicide in neurological disorders.

Accessible online at: www.karger.com/ned Suicide is an avoidable tragedy. The clinicians’ interest and vigilance are the most potent available deterrents. Individuals in high-risk groups can be identified, and practical, effective interventions are available. A number of neurological disorders have been identified among risk factors for suicide, so it behooves neurologists to be mindful of these conditions and to have a general awareness of suicide potential and management options. In the accompanying article, Fredrikson et al. [1] confirm an elevated risk of suicide in patients with multiple sclerosis. The twofold increase in standardized mortality ratio was comparable with that found in an earlier Danish study [2]. The methods by Fredrikson et al. [1] were excellent, yet in interpreting their work, it must be remembered that their lengthy data collection period was mainly in a period of relative therapeutic nihilism, before ß-interferon became available. Now that effective treatments for multiple sclerosis are available, the hopelessness of sufferers may be mitigated. The highest risk of suicide was amongst younger males in the early years after diagnosis. Male gender is a very well recognized risk factor for suicide, partially because of its association with alcohol abuse. Other neurological disorders also confer an increased risk of suicide [3]. Stroke increases suicide risk [4]. Poststroke depression is often the soil from which suicide ideation emerges. The presence of persistent physical and cognitive impairments also contributes to suicide risk. Particular mention needs to be made of right frontal lobe strokes, which cause a motor aprosodia. In such instances, though these patients may complain of significant dysphoria, hopelessness, and suicide ideation, their inability to convey emotionality and feeling can cause disbelief in observers who tend to underestimate the severity of such utterances [5]. Huntington’s disease carries an increased risk of suicide. In his original article, Huntington [6] stated ‘the tendency to insanity and sometimes to that form of insanity which leads to suicide is marked’. Huntington patients are at risk for a plethora of psychiatric disturbances including mood disorders, psychosis, and personality disorders [7]. Even asymptomatic individuals at risk for Huntington’s disease need to be carefully screened for suicide ideation, before and after predictive genetic testing is carried out [8]. Epilepsy also carries an increased risk of suicide [9]. In addition to comorbid psychopathology, other factors increasing risk include higher seizure frequency and the need for multiple antiepileptic medications [10]. Temporal lobe foci may be a risk factor, but it may be their association with psychopathology that leads to suicide risk. Occasionally effective treatment results in the phenomenon of forced normalization wherein seizures are controlled but mental status deteriorates, sometimes dramatically so [11]. Vigabatrin has been associated with depression, but most newer antiepileptic drugs are either psychiatrically benign or even beneficial, i.e. divalproex and