By: Stefania Pierce
The Link Between Suicidality and Epilepsy
The symptoms of epilepsy extend far beyond its defining feature of recurrent seizures. It is a condition that can profoundly shape emotional well-being, social functioning, and quality of life. While medical advances have improved seizure control, the psychological and social consequences of epilepsy are still often neglected. Among these, suicide stands out as one of the most tragic and underrecognized outcomes. Individuals with epilepsy face a markedly elevated risk of suicidal thoughts, attempts, and deaths compared to the general population, even when psychiatric comorbidities such as depression and anxiety are accounted for (Jacob et al., 2020). This persistent and troubling association underscores the need to view epilepsy not solely as a neurological condition but as a disorder with far-reaching psychiatric and psychosocial dimensions.
Suicide in this population can be attributed to a complex interplay of neurobiological vulnerabilities, psychiatric comorbidities, and environmental stressors that can shape risk throughout the lifespan. This essay explores the historical and epidemiological understanding of suicide in individuals with epilepsy and examines how psychiatric, clinical, neurological, demographic, and social factors contribute to suicidal behavior. Using this data, the paper will highlight the urgent need for systematic screening and expanded research to ensure that at-risk individuals receive timely, comprehensive care.
Epidemiological Data
The association between epilepsy and suicide has been well documented for more than a century, but its significance was long underestimated among many clinicians in the field. Early clinical observations often dismissed suicidal behaviors among individuals with epilepsy as attention-seeking or secondary phenomena rather than concerns of genuine psychological distress (Prudhomme, 1941), contributing to a lack of understanding of the topic. However, as more research has become available, the high prevalence of suicide in this population has become increasingly evident. In one of the earliest systematic investigations, Lennox and Lennox (1960) found that 9.3% of individuals with epilepsy had died by suicide, an extraordinarily high rate compared to less than 0.5% in the general population. They attributed this elevated risk to a phenomenon they termed “epileptic despair,” characterized by the profound psychological burden of the disorder, including severe social limitations, alternating periods of health and debilitating illness, and a pervasive belief in inevitable mental deterioration.
Studies in the mid-20th century continued to reinforce these observations. Kurtz (1972) reported that, in one epilepsy center, approximately one of every 600 patients died by suicide each year, highlighting suicide as a recurrent and measurable outcome rather than an isolated occurrence. Similarly, Matthews and Barabas (1981) analyzed 1,150 deaths among individuals with epilepsy and found that roughly 5% resulted from suicide, which yet again proved to be considerably higher than the 1.4% suicide rate observed in the general U.S. population. By the early 2000s, research methods had evolved to where large-scale epidemiological data could be interpreted and assessed. Using mortality data from across the United States, Nilsson et al. (2002) identified suicide as a major contributor to the elevated mortality rate among people with epilepsy. As a more recent example, Tian et al. (2016) reported that adults with epilepsy had a 22% higher suicide mortality rate than the general population between 2003 and 2011. Collectively, these findings demonstrate a longstanding and well-documented relationship between epilepsy and elevated risk of taking one’s own life. The persistence of this association over time and across methodologies emphasized the necessity of investigating the psychiatric comorbidities that may exacerbate or contribute to this vulnerability.
Psychiatric Comorbidities
Clinicians and researchers have recognized the strong link between epilepsy and psychiatric disorders for more than three decades (Ott et al., 2003). Psychiatric comorbidity has been found to be highly prevalent in individuals with epilepsy compared to both the general population and individuals with other chronic illnesses (Giambarberi & Munger Clary, 2022). This comorbidity substantially exacerbates mental and emotional stressors associated with this disease and is closely associated with increased suicidality. It has also been shown that people with epilepsy who also experience psychiatric disorders demonstrate significantly higher rates of suicidal ideation, attempts, and completed suicides than those without such comorbidities (Christensen et al., 2020).
Among psychiatric conditions, major depressive disorder (MDD) is the most frequently observed in people with epilepsy, with prevalence rates ranging from 30% to 35% (Lu et al., 2021; Tellez-Zenteno et al., 2007). Depression in this population has been found to not only be common but also more severe than that seen in other neurological conditions, suggesting a unique neurobiological and/or psychosocial connection between epilepsy and mood regulation (Mendez et al., 1993). Notably, this pattern extends beyond adult populations, indicating that depressive symptoms may emerge early in the trajectory of epilepsy. Dagar et al. (2020) reported similar trends of suicidality in children with epilepsy as in adults with the disorder. Their research found that more than 40% of children and youth with epilepsy screened positive for depressive symptoms, demonstrating that mood disturbances often emerge early in the course of the disease. The early onset and high severity of depression in individuals with epilepsy underscores the broader vulnerability to emotional disturbances within this population, including the frequent co-occurrence of anxiety disorders.
Anxiety disorders are the second most common psychiatric comorbidity among individuals with epilepsy, affecting over 25% of patients (Lu et al., 2021). Along with depression, anxiety plays a central role in the emotional burden of this group of people, with both conditions strongly correlating to suicide attempts in this population (Nigussie et al., 2021).
In addition to these affective factors, behavioral influences such as alcohol use (common in individuals with anxiety and depression) further compound vulnerability, as alcohol consumption has been independently linked to increased rates of suicide and suicide attempts among people with epilepsy (Nigussie et al., 2021). The high rates of depression, anxiety, and overall behavioral dysregulation among individuals with epilepsy illustrate that suicidality in this population cannot be understood in isolation. Rather, these psychiatric comorbidities interact dynamically with a range of biological, psychological, and social risk and protective factors that further influence outcomes.
Clinical/Neurological Risk Factors
A range of clinical and neurological factors have been found to contribute to the elevated suicide risk observed among individuals with epilepsy. The strongest clinical predictor of a successful suicide attempt is a prior suicide attempt, a pattern consistent with findings in the general population. Nilsson et al. (2002) reported that 46.2% of suicides among people with epilepsy were preceded by at least one prior attempt, underscoring the need for early identification and intervention in patients with a history of self-harm.
Beyond behavioral history, neurological characteristics of epilepsy itself play a crucial role in shaping vulnerability to suicidality. Both seizure frequency and seizure type have been identified as key determinants of suicidal ideation and behaviors in people with epilepsy. Individuals experiencing seizures more than once per month are significantly more likely to attempt or complete taking their own life compared with those who have less frequent episodes (Kim et al., 2020). Similarly, the type and localization of seizures appear to influence emotional outcomes, with focal seizures, particularly those involving the temporal lobe, being linked to higher rates of depression, anxiety, and suicide than generalized seizures (Lu et al., 2021; Munger Clary et al., 2018; Mbizvo et al., 2019). These findings suggest that seizure activity within limbic and temporal structures (regions linked to emotion regulation) may biologically predispose individuals to affective dysregulation and suicidal behavior. Suicide risk also appears to fluctuate across the clinical course of epilepsy. Christensen et al. (2007) found that vulnerability is highest shortly after diagnosis, suggesting that the psychological impact of receiving a chronic neurological condition may further intensify early suicidality.
The emotional and behavioral side effects of antiepileptic drugs (AEDs) also warrant particular attention, as some medications have been associated with mood instability and behavioral dysregulation, which could potentially exacerbate suicidal ideation in vulnerable patients (Hecimovic et al., 2011; Korczyn et al., 2013). However, more recent evidence indicates that AEDs themselves are not independent risk factors for suicidality in people with epilepsy, contrary to early FDA warnings, and that antidepressants such as SSRIs may even exhibit anticonvulsant properties when used at therapeutic doses (Kanner, 2016). Treatment responsiveness is another factor found to also influence risk. Individuals with drug-resistant epilepsy are approximately three times more likely to experience psychiatric comorbidities and suicidal behaviors than those whose seizures respond to medication (Kim et al., 2020).
While many aspects of the condition contribute to higher suicidality in people with this condition, not all comorbidities heighten risk. For example, people with developmental disabilities, although often affected by epilepsy, exhibit lower suicide rates, possibly due to protective factors such as enhanced social support or reduced engagement in risk behaviors (Mbizvo et al., 2019).
These findings highlight seizure characteristics, pharmacological effects, treatment resistance, and comorbid psychiatric conditions as collectively shaping this heightened vulnerability, reinforcing the need for fully integrated neurological and psychiatric approaches to patient care. While neurobiological and clinical variables clearly play a central role in shaping suicidality among individuals with epilepsy, they represent only part of a broader picture.
Demographic and Social Factors
Building on these clinical and neurobiological findings, it is equally important to consider the broader contextual influences that shape suicide risk in epilepsy. Demographic and social factors interact dynamically with neurological and psychiatric variables, amplifying or buffering an individual’s vulnerability to self-harm. Age, sex and social environment, along with family relationships, coping styles and broader socioeconomic conditions, collectively influencing how individuals experience and respond to the psychosocial burdens of epilepsy, Understanding these dimensions provides a more comprehensive view of suicidality in this population, emphasizing that risk is not solely determined by biological or clinical features, but also the social and emotional context in which individuals live.
Among demographic variables, age consistently emerges as one of the most influential factors. Younger individuals appear particularly vulnerable, with risk declining progressively with age. Harnod et al. (2018) reported that suicide risk decreases across the lifespan, emphasizing that youth with epilepsy represent a distinctly high-risk group. This heightened susceptibility in early life is further supported by pediatric research. Dagar et al. (2020) found that 11% of children and adolescents with epilepsy, despite having no prior psychiatric diagnoses, expressed suicidal thoughts, highlighting the unique psychiatric risk associated with early-onset of this disease.
Sex-related differences also contribute meaningfully to suicidal outcomes. Women with epilepsy experience significantly higher rates of suicidal ideation compared to men, whereas men demonstrate greater rates of suicide attempts and completed suicides (Nigussie et al., 2021; Abraham et al., 2019). These findings suggest that gender-specific psychological, behavioral, and sociocultural influences may shape the expression of suicidality within this population.
Beyond individual demographics, contextual stressors inherent to living with epilepsy further compound risk in this population. As early as 1960, Lennox and Lennox identified a range of epilepsy-specific challenges, including the chronic and unpredictable nature of seizures, dependence on medication, fears of genetic transmission, difficulty obtaining insurance coverage, and pervasive social stigma, that collectively create sustained psychological strain. Such cumulative stress may intensify hopelessness and self-destructive ideation, particularly in those lacking strong social or emotional support systems.
Social and familial environments have been found to be critical in modulating suicide risk. Individuals living alone or with limited social networks, such as those who are single, divorced, or widowed, demonstrate significantly higher rates of suicidal ideation (Nigussie et al., 2021). Family dynamics exert a similar influence, with higher perceived criticism from family members predicting elevated suicidality, but strong familial support has been shown to serve as a protective buffer against suicidal thoughts and behaviors (Batchelor & Taylor, 2021). In addition, a family history of suicide further increases vulnerability, independent of depression, suggesting intertwined genetic and environmental contributions to risk (Nigussie et al., 2021; Kim et al., 2020).
Coping strategies interact closely with these social factors, serving as critical mediators between external stressors and psychological outcomes. Individuals who rely predominantly on avoidant or emotion-suppressing coping mechanisms such as denial, withdrawal, or emotional numbing tend to experience greater psychological distress and higher rates of suicidality (Batchelor & Taylor, 2021). These maladaptive strategies can exacerbate feelings of isolation and helplessness by preventing individuals from seeking social or professional support, thereby reinforcing a cycle of emotional disengagement and despair. In contrast, adaptive coping approaches like problem solving, seeking emotional support, and reframing stressors buffer against the negative effects of challenges related to this illness. For people with epilepsy who often face ongoing uncertainty, stigma, and social limitations, the use of constructive coping strategies has been associated with lower levels of depressive symptoms and suicidal ideation. Interventions that promote adaptive coping and emotional resilience are therefore vital in reducing suicide risk and improving overall psychological well-being in the population.
The research has shown that suicide risk in epilepsy is deeply shaped by the intersection of demographic, social, and familial influences. Factors such as age, sex, social support, and coping style each contribute to overall vulnerability. Recognizing these determinants is essential for identifying high-risk subgroups and for designing preventive interventions that emphasize social connectedness, family engagement, and developmentally tailored mental health care.
Clinical Practice & Screening Gaps
Despite decades of evidence linking epilepsy to elevated suicide risk, suicide prevention remains an underrecognized and underaddressed component of epilepsy care. The consistent association across historical, clinical, and epidemiological studies underscores that this relationship is not incidental, but reflects a complex interaction between neurobiological vulnerability, psychiatric comorbidity, and psychosocial stressors. Depression, anxiety, treatment resistance, social isolation, and demographic risk factors collectively heighten susceptibility, yet systematic efforts to identify and mitigate this risk remain limited in clinical practice. In a 2020 survey of epilepsy health-care providers, only 5% reported screening for suicide at the initial visit, fewer than half of those did so during follow-ups, and 6% stated they never screened at all (Gandy et al., 2021). These findings illustrate a critical gap between evidence and implementation, revealing that many at-risk individuals may go undetected until crises occur. Routine suicide risk assessment, especially at diagnosis, medication changes, and during periods of increased psychosocial stress, should therefore be a standard component of epilepsy management. Moving forward, greater interdisciplinary collaboration between neurology, psychiatry, and psychology is essential. Research must continue to clarify the mechanisms linking epilepsy and suicidality, explore the protective effects of social and family support, and evaluate targeted interventions designed to reduce risk across the lifespan. Expanding screening practices and embedding mental health evaluation within standard epilepsy care could substantially reduce preventable deaths and improve overall quality of life for individuals living with this chronic neurological condition.
References
Abraham, N., Buvanaswari, P., Rathakrishnan, R., Tran, B. X., Thu, G. V., Nguyen, L. H., et al. (2019). A meta-analysis of the rates of suicide ideation, attempts, and deaths in people with epilepsy. International Journal of Environmental Research and Public Health, 16(8), 1451. https://doi.org/10.3390/ijerph16081451
Batchelor, R., & Taylor, M. D. (2021). Young adults with epilepsy: Relationships between psychosocial variables and anxiety, depression, and suicidality. Epilepsy & Behavior, 118, 107911. https://doi.org/10.1016/j.yebeh.2021.107911
Christensen, J., Vestergaard, M., Mortensen, P. B., Sidenius, P., & Agerbo, E. (2007). Epilepsy and risk of suicide: A population-based case-control study. The Lancet Neurology, 6(8), 693–698. https://doi.org/10.1016/S1474-4422(07)70175-8
Christensen, J., Vestergaard, M., Mortensen, P. B., Sidenius, P., Agerbo, E., & Conwell, Y. (2020). Association between neurological disorders and death by suicide in Denmark. JAMA, 323(5), 444–454. https://doi.org/10.1001/jama.2019.21834
Dagar, A., Anand, A., Pestana-Knight, E., Timmons-Mitchell, J., Tossone, K., Zemba, D., et al. (2020). Screening for suicidality and its relation to undiagnosed psychiatric comorbidities in children and youth with epilepsy. Epilepsy & Behavior, 113, 107443. https://doi.org/10.1016/j.yebeh.2020.107443
Gandy, M., Modi, A. C., Wagner, J. L., LaFrance, W. C., Jr., Reuber, M., Tang, V., et al. (2021). Managing depression and anxiety in people with epilepsy: A survey of epilepsy health professionals by the ILAE Psychology Task Force. Epilepsia Open, 6(1), 127–139. https://doi.org/10.1002/epi4.12455
Giambarberi, L., & Munger Clary, H. M. (2022). Suicide and epilepsy. Current Neurology and Neuroscience Reports, 22(8), 441–450. https://doi.org/10.1007/s11910-022-01206-6
Harnod, T., Lin, C. L., & Kao, C. H. (2018). Prevalence of suicide attempts and their risk factors in school-aged patients with epilepsy: A population-based study. European Child & Adolescent Psychiatry, 27(8), 1047–1053. https://doi.org/10.1007/s00787-018-1118-z
Hecimovic, H., Salpekar, J., Kanner, A. M., & Barry, J. J. (2011). Suicidality and epilepsy: A neuropsychobiological perspective. Epilepsy & Behavior, 22(1), 77–84. https://doi.org/10.1016/j.yebeh.2011.04.059
Jacob, L., Oh, H., Koyanagi, A., Smith, L., & Kostev, K. (2020). Relationship between physical conditions and attempted or completed suicide in more than 9,300 individuals from the United Kingdom: A case-control study. Journal of Affective Disorders, 274, 457–463. https://doi.org/10.1016/j.jad.2020.05.121
Kanner, A. M. (2016). Most antidepressant drugs are safe for patients with epilepsy at therapeutic doses: A review of the evidence. Epilepsy & Behavior, 61, 282–286. https://doi.org/10.1016/j.yebeh.2016.03.022
Kim, S. J., Kim, H. J., Jeon, J. Y., Kim, H. W., & Lee, S. A. (2020). Clinical factors associated with suicide risk independent of depression in persons with epilepsy. Seizure, 80, 86–91. https://doi.org/10.1016/j.seizure.2020.05.026
Korczyn, A. D., Schachter, S. C., Brodie, M. J., Dalal, S. S., Engel, J., Jr., Guekht, A., & Mares, P. (2013). Epilepsy, cognition, and neuropsychiatry (epilepsy, brain, and mind, part 2). Epilepsy & Behavior, 28(2), 283–302. https://doi.org/10.1016/j.yebeh.2013.03.012
Kurtz, J. F. (1972). Mortality and morbidity data on epilepsy. In M. Aller & W. A. Hauser (Eds.), The epidemiology of epilepsy: A workshop (NIH Publication No. 73-390, p. 151). U.S. Department of Health, Education, and Welfare.
Lennox, W. G., & Lennox, M. A. (1960). Epilepsy and related disorders. Boston, MA: Little, Brown and Company.
Lu, E., Pyatka, N., Burant, C. J., & Sajatovic, M. (2021). Systematic literature review of psychiatric comorbidities in adults with epilepsy. Journal of Clinical Neurology (Seoul, Korea), 17(2), 176–186. https://doi.org/10.3988/jcn.2021.17.2.176
Matthews, W. S., & Barabas, G. (1981). Suicide and epilepsy: A review of the literature. Psychosomatics, 22(6), 515–524. https://doi.org/10.1016/S0033-3182(81)73498-4
Mbizvo, G. K., Bennett, K., Simpson, C. R., Duncan, S. E., & Chin, R. F. M. (2019). Epilepsy-related and other causes of mortality in people with epilepsy: A systematic review of systematic reviews. Epilepsy Research, 157, 106192. https://doi.org/10.1016/j.eplepsyres.2019.106192
Mekonen, T., Getnet, A., Belete, A., Menberu, M., & Fekadu, W. (2020). Suicidal behavior among people with epilepsy in Northwest Ethiopia: A comparative cross-sectional study. Epilepsy & Behavior, 111, 107233. https://doi.org/10.1016/j.yebeh.2020.107233
Méndez, M. F., Doss, R. C., Taylor, J. L., et al. (1993). Depression in epilepsy: Relationship to seizures and anticonvulsant therapy. Journal of Nervous and Mental Disease, 181(7), 444–447. https://doi.org/10.1097/00005053-199307000-00009
Munger Clary, H. M., Snively, B. M., & Hamberger, M. J. (2018). Anxiety is common and independently associated with clinical features of epilepsy. Epilepsy & Behavior, 85, 64–71. https://doi.org/10.1016/j.yebeh.2018.05.024
Nigussie, K., Tesfaye, B., Lemma, A., & Kerebih, H. (2021). Magnitude and associated factors of suicidal ideation and attempt among people with epilepsy attending outpatient treatment at primary public hospitals in northwest Ethiopia: A multicentre cross-sectional study. BMJ Open, 11(1), e043227. https://doi.org/10.1136/bmjopen-2020-043227
Nilsson, L., Ahlbom, A., Farahmand, B. Y., Åsberg, M., & Tomson, T. (2002). Risk factors for suicide in epilepsy: A case-control study. Epilepsia, 43(6), 644–651. https://doi.org/10.1046/j.1528-1157.2002.40001.x
Ott, D., Siddart, P., Gurbani, S., et al. (2003). Behavioral disorders in pediatric epilepsy: Unmet psychiatric need. Epilepsia, 44(5), 591–597. https://doi.org/10.1046/j.1528-1157.2003.44502.x
Tellez-Zenteno, J. F., Patten, S. B., Jetté, N., Williams, J., & Wiebe, S. (2007). Psychiatric comorbidity in epilepsy: A population-based analysis. Epilepsia, 48(12), 2336–2344. https://doi.org/10.1111/j.1528-1167.2007.01222.x
Tian, N., Cui, W., Zack, M., Kobau, R., Fowler, K. A., & Hesdorffer, D. C. (2016). Suicide among people with epilepsy: A population-based analysis of data from the U.S. National Violent Death Reporting System, 17 states, 2003–2011. Epilepsy & Behavior, 61, 210–217. https://doi.org/10.1016/j.yebeh.2016.05.028
