Abstracts

Rationale: The Federal Drug Administration issued an alert in January 2008 regarding increased risk of suicidal ideation with antiepileptic drug use in patients with epilepsy. The risk was seen anywhere from 1 to 24 weeks after starting medication. Levetiracetam was amongst this group. Review of the literature shows that unwanted behavioral effects have been observed in 13.3% of patients on levetiracetam. Levetiracetam in association with suicidal ideation has been documented in several case reports. However, the outcome of these patients after documented suicidal ideation is lacking. Methods: We report two epileptic patients who developed suicidal ideation while being prescribed levetiracetam. A thorough review of these patients' charts was undertaken. Results: Case 1: A 30-year-old male with medically intractable complex partial epilepsy reported suicidal ideation after starting levetiracetam 6 weeks prior. He tried multiple antiepileptics in the past without any documented psychiatric complications. He was currently on valproic acid and gabapentin for 2 years when levetiracetam was added. He had anxiety disorder that did not require medication. He was placed on levetiracetam 500mg twice daily. He was on this dose for 2 weeks when it was adjusted because of complaints of irritability and continued seizures. His dose was adjusted to 250mg in the morning and 1000mg in the evening. Four weeks later he had suicidal ideation and was put on 24 hour observation. Levetiracetam was stopped immediately and valproic acid was increased. His suicidal ideation dissipated within 48 hours. The patient returned to his routine the following week. Case 2: A 37-year-old female with complex partial epilepsy was started on phenytoin and levetiracetam at a dose of 250mg twice daily. One month later she reported irritability but no suicidal ideation. Her seizures were controlled. No prior documented psychiatric illness. Four months later she returned to clinic with a plan to commit suicide. She was sent to the emergency room. Levetiracetam was discontinued while phenytoin was maintained. She had no breakthrough seizures. She was sent home the next day. Her suicidal ideation had passed. Despite her neurologist’s recommendation, she continued to take levetiracetam after discharge. Two months later she returned to the emergency room with severe depression. Levetiracetam was continued by the emergency room physician. Three weeks later she reported continued intermittent thoughts of suicidal ideation to her neurologist. Levetiracetam was discontinued again. Several weeks later, the patient continues to suffer from depression but has not had any further thoughts of suicidal ideation. She has been referred to a psychiatrist for further management of her depression. Conclusions: We report the natural history of two epileptic patients with suicidal ideation while on levetiracetam. Both patient’s courses are quite different. We propose all patients be followed closely after discontinuation of the drug to monitor for continued psychiatric complications.