Hello, everybody, and thank you for attending today's Ask the Expert webinar, Lifting the Veil, Recognizing and Mitigating Suicide Risks in Epilepsy. Please note that this webinar does offer continuing education credit. After completing the evaluation, you'll be taken to the evaluation immediately after the webinar. You'll receive an email when the on-demand version is available. Before we get started, I would like to take a moment to equate you with a few features of this live streaming technology. At any time, you may adjust your audio using your computer volume settings. On the right-hand side of your screen, you'll see the audience engagement window with navigational tabs at the top. The chat tab allows audience members to communicate with one another. To send a message to the audience chat, click in the text box and type your comment. To send a comment, press the enter key or the send icon. The Q&A slash polling tab is where you will ask the presenters questions. You'll need to enter your first and your last name to participate in any polls or to ask a question. To ask a question, click in the text box or type your question. When finished, press the enter key or click the paper airplane icon to send your question. All questions that you submit are only seen by today's presenters. Your questions will be responded to in the order in which they were received and will be addressed at the end of the presentation. I'd like to introduce today's moderator, Dr. Katie Bollinger, AES Psychosocial Comorbidities Committee member. The floor is yours. Thank you. Welcome, everyone, to our live webinar. This is Ask the Expert, Lifting the Veil, Recognizing and Mitigating Suicide Risks in Epilepsy. My name is Katie Bollinger, and I'll be moderating today's webinar. I'm an associate professor in the Department of Neurology at Emory University, and I'm also a member of the AES Psychosocial Comorbidities Committee. I don't have anything to disclose. We are joined today by our presenter, Dr. Margaret Gopal. Dr. Gopal is an assistant professor holding a Ph.D. in clinical psychology with a specialization in neuropsychology. She serves as an associate research scientist at the Yale University School of Medicine, working within the Yale Comprehensive Epilepsy Center and the Veterans Affairs Medical Center. She's done postdoctoral training in clinical psychopharmacology. She's also done additional training in neurophysiology at Yale University and surgical neurophysiology at the University of Connecticut. Dr. Gopal is also an active member of the American Epilepsy Society Psychosocial Comorbidities Committee. The objectives for today include that we expect learners at the end of the webinar to be able to identify the prevalence and risk factors of suicidality in patients with epilepsy, to develop competence in using screening tools for detecting suicidality in patients with epilepsy, to implement evidence-based strategies for managing suicidality in clinical practice, and finally, to understand the relationship between epilepsy characteristics and increased suicide risk. As we move forward with the webinar, please feel free to enter any questions that you have in the Q&A box. Our speaker will try to respond to as many questions as she can during the Q&A portion of today's presentation. I will now turn the presentation over to Dr. Gopal. Thank you so much, Katie, and good afternoon, everyone. Thank you for joining today's webinar, and a special thank you to the AES for providing this opportunity to discuss such an essential topic. It is truly my honor to speak today about recognizing and mitigating suicidal risk in epilepsy patients. I know that this is something that most of you here may have encountered in one way, shape, or form during your clinical care of patients. I have nothing financial to disclose at this time. Before we dive in, I just wanted to acknowledge that, given my background, I do have a bias towards prioritizing mental health care. I realize that this may not be the focus with other specialties, and rightly so. However, the humbling reality to all specialties of care is that if we ignore or dismiss this issue, it will eventually resurface, or worse yet, we may no longer have that patient to treat. Reflecting back, I think currently I'm working on a project that keeps me closely attuned to mental health challenges when integrating mental health care to patients with epilepsy, and this is on a national level. I have to say that I've been surprised by the variability in responses of feedback from professionals of the challenges that they have seen. Some of you are here today, and thank you for being here. I know that this is indeed a delicate topic, and some of you face it head-on, while others just freeze or scramble for a treatment plan or care. Actually, I've heard one response that caught my attention, and in that response, that professional was suggesting a separation of care focus. Specifically, it was in the line of, I have to focus on the seizure control or treating the epilepsy. Within the time constraint, it's very difficult to address these other things, and I do hear that individual's dilemma. However, we have seen that over 68% of adults with mental health illnesses also have medical conditions. Herein, getting this feedback is what really drives my talk today, and I am so grateful to each of you for prioritizing this into your very busy schedule. It is my hope that during this brief talk that there'll be some takeaway that can add to your care of patients with epilepsy. Why this talk? This topic has been deemed a costly problem, and if we look at it from a patient perspective, it's indeed very costly if left untreated. It also has an impact to healthcare providers and the healthcare system as a whole, and there's been a clear identification of a professional practice gap. In fact, the ILAE has created a task force that was charged with taking steps to improve global mental healthcare for patients with epilepsy. In that, they have surveyed 445 participants from 67 countries, and the completion rate was amazing. Of that 87% of completion, the responders, 80% were from the group of neurologists and epileptologists. Interestingly, the key findings from that was less than 50% reported feeling adequately resourced to manage depression and anxiety. About 33% indicated that they would assess only after a spontaneous report. And then looking at some of the common barriers, a theme that I heard, which I also heard during interviews with different professionals, was the lack of time. So greater than 50% identified that, and greater than 55% addressed the issues with having trained mental health specialists, and greater than 38% reported issues with having standardized procedures. Another interesting thing that jumped out to me while reading this from the ILAE task force was that about 33% of professionals indicated that they take a more watchful waiting approach when treating patients with epilepsy and suicidality. So addressing this problem and gap is of importance. And so I want us to just look at some target areas, and then some quick and more practical steps that can be taken. So there are three areas I want to focus your attention on, and that's the very low screening rates, the under-diagnosed and under-treatment, as well as the impact on patient outcomes. So despite recommendations from epilepsy quality measures, the screening of suicidality remains critically low. The AES Psychosocial Comorbidities Committee has pointed out that even though we know screening is essential, it is not being routinely done. So this gap in care leaves our patients vulnerable, and many clinicians may underestimate the prevalence of suicidality in epilepsy patients. And also, research highlights that the suicidality in epilepsy patients is often under-diagnosed and under-treated, and this in turn leads to poor health outcomes. The other issue is the impact on the patient's outcomes, right? So the lack of proper screening and treatment contributes significantly to the adverse outcomes in this very vulnerable population. So what can we do? So some steps that I want us to focus on in a very practical way is how can we better first notice? And by notice, I mean how can we quickly identify those red flags, right? Then number two, how can we understand or get a better sense of what we're dealing with? And also, number three, response. How do we respond? How can we respond within that particular visit, as well as within the healthcare system that you work in, right? So we want to customize this and not make it a cookie cutter approach. And so I want to take a deeper look into what are some ways we can first notice and then develop that understanding. So I'll focus your attention towards looking at and understanding the frequency, looking at some predictors, as well as some risk factors. And for some of you, this may be something you already know. For those, I say, you know, let this be a refresher. And we may have those in the audience that are hearing this for the first time. And so I may go into some depths of things. But one of the most concerning aspects is that suicide rates among epilepsy patients are significantly higher when compared to the general populations. And studies consistently show that people with epilepsy are at increased risk for suicide ideation, as well as attempts, and sadly, completion. So it is something that we need to address head-on because it's not just a mental health issue. It's a systemic issue in epilepsy care, right? And so this now brings me to looking at some predictors. And I would say if you don't take away anything from this talk, there's just two things, these two predictors I want to really hope that you're able to take with you. Because a lot of times when I would chat with neurologists or epileptologists or even nurse practitioners and those treating patients with epilepsy, I often hear them comment about, we really want to know the screeners. We really want to understand how can we better assess our patients. But I want to take you backwards to a pre-screen, so to speak, that you can do in that very early encounter, like the first minute, the first five minutes, where it's more of a clinical judgment where you as a healthcare provider can quickly identify predictors, right? And the first quick thing you can hone into and capture with your patient is a history of prior suicide attempts. So a patient who has previously attempted suicide has been shown to be at a significantly higher risk for future attempts or even completion, right? So this history is one of the greatest predictors of suicidal behavior, and we should not ignore that. And in fact, this should be one of the things as a healthcare provider that should quickly jump out to you and say, okay, I need to focus in on this particular patient, right? And then the second is more of a paradoxical risk that comes up, and it is seen with more of an increased energy or even improved quality of life that's reported by your patient, and this is usually after a period of depression. And again, when I talk to some of my colleagues, they have said to me, I don't understand. My patient was doing really well. I even hear from family members. They'll say, well, we took a backseat in Mary's life because she was doing so well. We don't know how she got here. So I understand that this can seem counterintuitive, but sometimes when a patient begins to feel better or gain more energy, they may now be in a place where they're physically and emotionally capable or have the capacity to follow through on suicidal thoughts, whereby in the state of depression, they may not have been able to because they're too drained to act on that before. So this is why that sudden improvement in mood or energy in a patient with particularly a history of suicidality should be carefully monitored. So you want to hone in on that and pick up on that and not dismiss that as, oh, my patient is doing great, right? And so next I want to touch a bit and focus our attention on some risk factors. And again, these may all be things you've heard before, but we're just going to go through them so they're more of a refresher, reminder, or you have your quick mental cheat sheet that you can go to. And so the first is the psychiatric comorbidities. And we know that many epilepsy patients also experience psychiatric conditions like depression, anxiety, bipolar disorders, and more. And these comorbidities are some of the strongest predictors of suicide risk. And unfortunately, they often go unrecognized and untreated in this population. We also should note that there is this bi-directional relationship whereby epilepsy increases the risk of suicidality and vice versa. And so that's something to keep very, very much prominent in your minds. And studies have indeed confirmed that there is a higher rate of epilepsy in individuals with prior suicidality and psychiatric disorders. And then the next risk factor, which many of you I would imagine is very familiar with, is just a side effect that comes with the treatment of epilepsy. And so it's the anti-epileptic drugs. So while AEDs are critical for controlling seizures, some of them in fact carry side effects that can contribute to mood changes, depression, and suicidal ideations. So it is important to monitor those patients carefully, especially if they report new or worsened psychological symptoms after starting or changing medication. So those are things that you want to have an early read on your patient as you're about to see them. You want to flag those things. Now the next one, the social isolation, is sometimes missed. But as we know, epilepsy can be an isolating condition. So the stigma that's associated with seizures, along with perhaps a fear of having a seizure in public, it can often lead patients to withdraw from social interactions. And this isolation can then deepen a sense of loneliness or despair or hopelessness, which in turn all contribute as risk factors for suicidality. So you want to have that conversation with your patient. You can start off like, hey, how was your weekend? And sometimes you can pick up on things where they might say, oh, I didn't do anything. I'm just staying by myself. And so you can ask them, how are things in school? And so there are very subtle ways of pulling this information out of your patient in the very first minute or two or even five minutes into that visit. And so the next one we're all well aware of is just the seizure-related stress. So as we know, living with the unpredictability of seizures can really cause significant stress to patients. And we may see that patients are constantly worrying about when and where the next seizure will happen. And they may also perhaps have fear of just the injury or the embarrassment, which can become very overwhelming. And so this chronic stress coupled with the physical toll of seizures in itself can lead patients to emotional exhaustion and just increase that risk of suicide. Now, as we move on to trying to understand suicidality among patients with epilepsy, I just wanted to cover a little bit of the myths. And I know that many of you may have heard this. Again, I just want to go over these really quickly. And the first myth is that we may hear that talking about suicide increases the chance that a person will act on it. Not true. Number two, people who talk about suicide, oh, they're just seeking attention. Not the case. And number three, suicide cannot be prevented. As we know, it can be prevented. Or people who take their lives are just plain old selfish, cowards, or even weak. And I've actually heard some folks say this, that those that are at greater risk are just the teenagers and the college students. Not true. Or why do we even bother to have barriers to bridges or firearm storage or security measures or even limiting access to lethal methods because it's just not effective. And also, talk therapy and medications really don't work. Not true. Or that suicide always occurs without warning. Now, that's definitely not true. Based on what we talked about earlier, there are definitely red flags, right? There are early signs. Both healthcare providers, friends, peers, family members can pick up on these things. I mean, if your patient comes in, there are certain things that you can quickly look at. For example, any major sleep pattern changes, right? You can quickly identify whether they're social withdrawal. Are they dropping out of group activities? Any recent death of a close friend or relative by suicide. We talked about prior attempts, right? Prior attempts of suicide. Looking for any shifts in mood or irritability, any recklessness or apathy. So these are all things that we can be very attuned and have ready. They're not formalized screens, but they're your pre-screen that you can quickly execute in the early stages of a visit. Now, we've discussed some of the key risk factors and things to be aware of. And I wanted us to shift gears a little bit and engage with a patient case. So I want to invite you to walk through this case with me, taking your time to use the notice, understanding, and response approach. And how can you arrive at the best course of action for this patient? I want you to make this your own. You can think of another patient, perhaps. And I want you to apply it within the healthcare system or the practice so that it's applicable and it's very practical, right? So as we looked at this case, let's focus on what we need to notice. So here we have John. John is a 35-year-old male with a 10-year history of epilepsy. He's recently diagnosed with depression, and he's currently on anti-epileptic drugs, including levothyrosin, which we know can sometimes have psychiatric side effects, right? And so in addition to that, the other important area to notice here is that there is this increasing social withdrawal, right? And he's reporting feeling better off dead. Also, we have the family concerns about mood swings and irritability. So these should immediately raise red flags for potential suicidal ideation in John's case. Now, I want us to take a little bit of a step back and just quickly go over some types of suicidal ideation. So the suicidal thoughts may manifest in either passive or active ideation. And the passive ideation is when a person thinks, I wish I was dead. And this is what we're seeing right now with John, right? He's reporting the feelings of, I'm better off dead. And on the other hand, you have the active ideation, which is when someone is actually planning to end their life. And the risk escalates at this point significantly when this shift happens. So it is important as a health care provider to understand the progression from passive thoughts to active plans, right? And typically, it starts with a passive ideation, like we're seeing here with John's case, which if not addressed, it can then progress to active thoughts, then to planning, and finally, an attempt or even completion. So knowing where your patient is on that spectrum can really guide your response or your intervention strategy, right? So in this case, we see the early warning signs that need to be addressed immediately to prevent further escalation. So in this case with John, I would suggest we explore his thoughts a little bit more to determine if indeed he has a plan and provide that necessary support. And I know that some of you may be thinking, well, how could I do this practically, right? Given the time constraints. And so an immediate response could be simply an expression of care. So I call this soft skills, right? So you want to make sure that you want to avoid, in fact, offering any fixes to the problem or even sharing your own perspective. Here, you want to mostly listen and reflect back on what is being shared to you. Try as much as possible to avoid any judgment and remain as neutral as possible. You want to make sure that you're acknowledging and very, very importantly, validating that emotion, right? And while this part may not apply to John's case, you want to be careful to, or mindful rather, to categorize your response. Or mindful rather to catch any sudden burst of energy that you might be hearing being reported or quality of life. And be mindful that this may or may not, in fact, be a situation where that patient is now being motivated, now have the clarity to follow through on any thoughts or plans that they may have had, right? And so practical ways to respond will include screening and identification. So early identification of at-risk individual is essential in suicide prevention. By applying these tools, which we will talk about, we can see how this can quickly help us to further identify the level of risk that John is facing with. And understanding that level will then better inform how we can intervene and to protect his well-being, right? So some of the tools that can be used, and I know many of you are familiar with this, is the Mini International Neuropsychiatric Interview, which we simply call the Mini. The Beck Depression Inventory and the Columbia Suicide Severity Rating Scales. And these are all tools that we can use in a formal way to assess that patient. And I want to be realistic in addressing the concerns that were brought to me and that I hear about often. And that is, how can we practically apply these screens with limited time, right? And so some ways to address this dilemma, I would say, first, just try to use short-form versions and focus on the most relevant sections. So for example, for the Mini, I would say focus on the mood disorders, the anxiety, and suicidality. And you want to look at what's most pertinent to the patient's immediate presentation. This would allow for a quicker assessment while still identifying any psychiatric issues, right? If you're working with the Beck Depression Inventory, now, this is a self-report measure. So in fact, you can have the patient complete this before the visit or let's say it was not done prior. And you're in the visit and you're starting to see those little flags, red flags, and you're saying, okay, you can have that completed during the visit. It can be done very quickly and you will have a quick view as a score which can help inform the direction in which you treat that patient. Let's say you're looking now at the Columbia Suicide Severity Rating Scale. This too can be administered in a very quick way by pulling out key questions. So focusing on the most critical aspects. So for this, I would say looking at recent thoughts of suicide, intent, or any planning. And this version is actually friendly to be adopted to, I would say, take about less than five minutes. And it will give you a very nice snapshot of the patient's risk. So overall, I would say my suggestion here would be to prioritize the most pressing tool based on the patient's symptoms and situation. So for example, if there is a clear depression and suicide risk, you may first administer the Columbia Scale quickly, then follow up with the Beck, and then the Mini if time allows. But always ensure that the tool you're using align with the urgency of the clinical presentation. Now, continuing with responding from a clinical intervention perspective, we know that there's a challenge. The challenge often is with the immediate action, right? But I wanted to take a step back and look a little bit of how can we prepare prior to that. So it's important to establish and know how to navigate the individual referral system within your institution or within your healthcare system, right? And I strongly suggest having a contact person. Now, I realize that every hospital system may be different. So please make that effort prior to understand your system to even identify if there are any gaps. And perhaps you can even initiate and make suggestions for improvement that you may have noticed. And I have gotten feedback from others about their system and some of the gaps that they have noticed or even things that work, right? So it is possible to try as much to customize things in a way where we say there's a warm referral. And again, I know this varies in smaller systems. This might be more realistic, but then it might not be as feasible in larger hospital systems. And the goal here is you want to make a referral, close the loop, and to make sure that that patient is not falling through the cracks or that they're actually having what we call a warm handoff. And so in John's case, the initial step will be the screening, right? And then the immediate action, let's say John shows active suicidal ideation with a plan, we should then refer him to emergency psychiatric services and just do our best to make sure that there's a warm handoff and that you know that John has been plugged in, right? We also want to make sure that we have a multidisciplinary approach. And I know many of us do that. And also be mindful of the medication and reviewing that for John. So like in John's case, to assess the impact of levothyroxethamine on his mood, and if indeed you think this is influencing his mood and potential suicidal thoughts, then you may consider switching to another AED with a lower risk of mood disturbances. And then also you want to be mindful of the family involvement. So ways that you can educate John's family about the signs of worsening depression or suicide ideation, and just plugging him into any support system or peer groups that may be helpful. So in terms of response for the overall clinical approaches, you want to make sure that you have integrated care. You want to personalize that care for John or any of your patient just so it's individual to that patient. Make sure that you're accessing and connecting to that support network and involving just having regular follow-ups and checkups for John. Now, very important is the long-term management, right? You want to make sure that you have frequent appointments to monitor John's mood as well as the seizure control, making that adjustment based on his progress. So it's just not, here's your treatment and see you back in six months. Also considering that John has some sort of therapeutic intervention, perhaps CBT that can address depressive symptoms and suicidal thoughts. And again, trying to plug him into any sort of group for individuals with epilepsy to help with the social isolation. And of course, making sure that John is set up with sort of a safety plan, which includes emergency contacts and steps to take if suicidal thoughts should intensify. And so the call to action here is more performance and knowledge needed. Again, screening, screening, very important. Practitioners need to be aware of the prevalence and then being mindful to screen. And that, again, will be customized based on the patient's needs and what you're seeing, risk factors, predictors, those sorts of things. And then developing the skills needed, whether it's a soft scale, whether it's just working on that ability to use the right screens, understanding them, or just understanding your referral system that you have. So that's a very individual question that as health care providers, we can ask ourselves and tap into those areas that we need to develop. And there's a vast number of resources and ways to develop those skills. And the other very, very important area is to be able to build that rapport with your patient, where in the very early stages of that visit, they can have that comfort of open communication. So you want to foster that environment where the patient feels comfortable to share things with you, because a lot of times this is a very sensitive area and they may try to mask how they're feeling. And then, of course, support. We always want to continue research that helps us to better understand ways that we can mitigate suicidal risk in epilepsy patients. And so in conclusion and the takeaway, we want to be aware of how can we notice, how can we grab those early red flags, improve our understanding, and very importantly, how can we respond, right? So regular screening, very important for timely intervention. Understand the red flags. Know that it's unique to each patient. Know the risk factors. Know the predictors. Tap into that multidisciplinary team, which can definitely enhance the management of patients with epilepsy. And developing your own skills in the areas that you need to. And again, just keep in mind the myths and the barriers that are there, and that can help to improve the patient-provider communication that you have with your patient. And so that concludes my presentation. I would like to share my contact information here with you. And also some resources if needed. And finally, but definitely a huge thank you to the American Epilepsy Society, especially the Psychosocial Comorbidities Committee, and my other colleagues for their contribution, their support, their feedback during this preparation. That has guided my talk. And here are my references. And thank you very much for your time. Thank you so much, Dr. Gopal, for that wonderful presentation. We will now move on to the question and answer portion of the webinar. And we do have some questions from the audience members. And so I will start by asking, how real do you think is the association between anti-seizure medications and suicidality? We know that there are a number of warnings on the medication labeling, and the question has come in, how real do you think that that association is? I think that's a, so that's, first of all, that's a really good question. And yes, it is a very real and researched evidence that we have existing with, and I'm trying to think of a paper right now, I do have one source that's listed in there that lists and highlight medications that actually are safe. So the SSRIs are safe for depression and anxiety, and then there are some that actually make the situation worse. And so we have, for example, some of the TCAs are on the flag. And so they are, if you look at the resources that has been provided, they are evidence of research that has been done that do link and shows that bi-directional connection. Thank you. We will move on to the next question, which is, does the onset of epilepsy increase the chance of depression? And I'm not quite sure if this is referring to the age of onset or the location of onset, but perhaps you could answer both of those. So does the onset, location onset of the epilepsy, increase the chance of depression, meaning if it comes from the temporal lobe or if it comes from the occipital lobe, versus if it's a generalized epilepsy? And then the secondary question being, if a patient develops epilepsy at a younger versus older age. Yeah, that's a great question. And I may defer that to you, Katie, in terms of location of the seizure and whether that makes it worse. And I would imagine the second part, could you repeat the second part of the question? Just whether the age of the onset impacts the likelihood of developing depression. Yeah, so the age of onset, if we think of when I spoke about the chronic stress, right? So someone dealing with this at, let's say in their 30s, may have a better resiliency and ability to cope. And so early onset increases that level of seizure risk stressors. And so in that case, you want to flag younger folks with early onset, you want to flag for integrated care. You want to make sure that they're plugged into not just the neurologist, but the psychiatrist or mental health provider, or even that they are receiving that other sorts of therapeutic approaches of cognitive behavioral therapy, because early onsets may predispose that person to chronic stress. Thank you. Just from an epileptologist standpoint, as far as location of the seizures, there certainly are different associations between the psychiatric comorbidities that we can see between epilepsy types. And so patients with temporal lobe epilepsy do tend to have a higher association with things like anxiety or depression. And that is likely a result of the epilepsy involving the limbic system. I will go ahead on to the next question. So there is a comment about one of the challenges for pediatric neurologists in their ability to get timely outpatient psychiatric evaluations, including therapies as well. So cognitive behavioral therapy or other forms of therapy are difficult to set up, and they can have long wait times, or often they're not covered by insurance companies. So the question is, what do you think about epilepsy specialists making contracts for safety with the patients who are expressing suicidal ideations? Have those been effective? And do you think that that would be an effective method for dealing with the shortages that we have with psychiatric care? Yeah, great question. So it is unfortunate that we have that wait list or we have that challenge. However, so if I'm understanding the question correctly, so the question is that if a pediatric neurologist or epileptologist making that contract with the patient or the patient and family would be effective? That's correct. OK, so yeah, but I want to step back and say this is where competence and preparedness is important. So there is, while it's ideal, it's something that we need to follow up with so that epileptologists need to be sort of have that skill set or training to be able to not overreact because I will go back to my early days of training and in dealing with patients that are perhaps suicidal, whether it's a passive or whether it's an active ideation. And sometimes in making that contract for safety, we can overreact or under react. So there's a level I would suggest some degree of training. There are a lot of resources out there, but definitely to answer the question, yes, it will be great. It's a great middle ground until we can get that patient to the right mental health provider. But I would also caution and say some level of or degree of training or development of skills would be needed. Thank you for that. You had discussed administering different suicidality screening inventories at clinical visits, and I'm curious, how often do you think patients with epilepsy should be screened? Yeah, great question. So screening should occur regularly, especially if we are identifying any major life stressors or psychiatric diagnosis or, again, any kind of medication changes that may occur. And so annual screening can be the baseline, but for higher risk patients, they should be assessed definitely more frequently. So the higher risk patient would be, I would say, some of the earlier talks that I shared about predictors, right, and risk factors. So if you have a patient and you're starting to notice, okay, this patient falls into this risk factor or you are looking at predictors and you notice that this patient had prior history of suicidality or this patient has other red flags that are coming to you, then you definitely want to be sure to assess that patient more frequently with screening. And I think that that's one of the issues where we may be seeing a lack of screening because a very standardized method may be being applied to patients. So every patient that come in may be getting an annual screen as baseline, and then thereon, perhaps depending on the institution, maybe six months or three months or whatever it may be. But the thing we want to keep in mind here is that we need to have some flexibility with screening. So it needs to be on an individual basis with that patient where we can assess more holistically what is going on with that patient. So I may have John on one hand that I may fast track his screening with him, whereas when I see Mary based on her presentation, I may say, I'll see you back in six months and then we do a screen. So I think that's a great question. And I hope that as we as we we have seen, you know, screening is an issue that is lacking. And and so when that is lacking, it kind of translate into how the response or the intervention. And so I certainly hope that this talk helps highlight that or bring that awareness to all of us. Yeah, that's very interesting. I'm aware of some centers that have screening as part of each visit, but other centers that don't include screening for suicidality at all in the visits. And it's really interesting to hear what you say, because it sounds like, you know, not screening, not screening at all is problematic, but also, you know, very regimented or subscribed screening might also give you a false sense of safety when that may not be the case. Yeah, very, very true, Katie. And thank you for making that point. Absolutely. We have another question or comment from the audience. They are asking about the role of the caregiver in observing suicidal ideations. And so I would like to ask you, how can family members or caregivers be involved in preventing suicide in patients with epilepsy? Yeah, amazing question. Thank you so much for that, because that's actually I did have a slide addressing patients. And because of time, I did take it out. So thank you so much for bringing that up. So family members, even very close friends, can play a very, very important role. And I think that the way they can as their medium to inform health care providers, that's one way. Because in communicating with families or even close friends, we can get a sense of where the patient is in terms of their mood, in terms of their social interactions. And I have seen places where there's some centers and facilities that may actually engage families with sort of a brief questionnaire or survey that gives them a sense of where the patient may be. And of course, this applies a lot more to teenagers, sometimes can get challenging with adults because we oftentimes need that consent. We don't want to just get information from family unless that individual is on board with that. But definitely involving family, involving family in, I think I mentioned in one of the slides, just their patient family education. So just having the family be aware of what they can look for as flags, as warnings, like the entire couple of slides that I presented can apply to family in knowing predictors, knowing risk factors, understanding the effects that the medication can have on their loved one. Right. It's key to have that. So sometimes we tend to have a myopic view and we think that everyone understands this. And so sometimes to go back to ground zero and go over some of the issues that families may be facing from their perspective of dealing with their loved ones, just to be able to go back and address that and have them have an active role in that treatment and in that care can be very, very effective both to the family and to the patient. Thank you. So as a clinician, I have a question for you, which is that we have so many tasks to take care of during a clinical visits. We have to do chart review. We, of course, need to spend time speaking with our patients about how they've been doing. We have to perform a neurologic exam. We have to take care of their epilepsy, including placing orders. We have to document. There's an awful lot of things that we need to do within a very short period of time. We're often given 20 to 30 minutes for each patient. And so I would just like to ask you, how should clinicians balance screening for suicidality and then also responding to if a patient is telling us that, yes, they do feel suicidal, the balancing, the screening and the managing suicidality with these limited times that we have in clinic? Yeah, that's a great question and a great dilemma, right? And I said, thank you so much for that, Katie, because it's one of the things that really prompted this talk for me is I've been working on a project and I've met with quite a few professionals across the United States, so in a national level. So it's not isolated to certain states. And so the common theme I've been hearing is that challenge. It's like everyone's on board. They recognize this is an issue, something we need to care about and do. But one professional actually said to me, I feel sometimes like my hands are tied. My patient is there. I am limited. And so some of the things that I suggested and we certainly welcome suggestions from others is prioritizing the relevant tools, right? There are many tools out there that we can use, but you want to truly listen to your patient, get a sense of what is being immediately the clinical presentation and then customizing the tools for the actual presentation. And then a further level of customization where those tools are being used as full length. So, for example, the Columbia Suicide Rating Scales, you want to just quickly focusing on the critical aspects such as the suicidality and the planning. And so you're not taking a lot of time to look at that and we can get quick assessments, quick flags. The Beck Depressant Inventory can also be customized where you are quickly getting a sense of your own judgment. So you're catching the red flags early, like I mentioned, but then you're also using these more. So your red flags would be more of the subjective. And then you want to have some objective. So you'd get a quick number when you look at the Beck Depression Scale or you look at the Columbia Suicidal Scale, you can get a quick snapshot of where your patient is. And then the next step would be what I talked about is having that prior setup where you understand your referral system. So you can very easily say, OK, my patient is here, they're at the intermediate level. I really want to escalate this. Here is the contact that I go to. So that kind of eases your burden and moves your visit along in a timely manner. And I certainly hope that helps. Thank you. That's very helpful. Seeing no additional questions, we will go ahead and wrap things up here. So thank you, Dr. Bhopal, for the wonderful presentation and for answering all of our questions. On behalf of the AES, I'd like to thank everyone for your participation in today's event. We'll have a recording of the webinar will be sent to you within 7 to 10 days. Please do be sure to complete the webinar evaluation in order to claim your CME credits. And that concludes today's presentation. Thank you again, everyone.

suicide risks

epilepsy

healthcare professionals

risk factors

suicidality

screening tools

multidisciplinary approach

caregiver involvement

clinical challenges