Levetiracetam and Suicidality: A Case Report and Literature Review

To identify clinical characteristics common among epileptic patients prescribed levetiracetam who report suicidal ideation or who exhibit suicidal behavior. A case is also provided that highlights the need for increased vigilance for neuropsychiatric sequelae in fragile epileptic patients prescribed levetiracetam, especially post dosage adjustment.

PubMed was queried with no time limitation to December 2018 using a combination of controlled terms. Using the Boolean operators "AND" and "OR," the authors searched PubMed for case reports and case series on levetiracetam-related suicidal behavior. The search terms used were [levetiracetam] OR [Keppra] AND in combination with suicidal, suicide, suicidal ideation, suicide attempt, and suicidality.

Relevant English-language human studies on levetiracetam and its effect on suicidal behavior were included. The search terms generated 78 results from the databases. After excluding all duplicates and applying the inclusion and exclusion criteria, a total of 14 clinical studies were retained for review.

Two reviewers independently extracted relevant data and assessed the methodological quality of each study.

The included studies reveal a number of risk factors for suicide ideation, suicide-related behavior, and suicide attempt among individuals taking levetiracetam. These risk factors include a prior psychiatric disorder, a history of traumatic brain injury, a history of substance use disorder, and a structural brain abnormality. Patients with these risk factors constitute a specific subgroup of patients with epilepsy who have an increased vulnerability to suicidal ideation or behavior if prescribed levetiracetam. These patients should, therefore, be monitored closely.

Suicidal behavior in epileptic patients appears to be multifactorial in etiology. Psychiatric disorders are more prevalent in epileptic patients than in the general population and contribute to this risk. In spite of the high risk of suicidal behavior with the use of antiepileptic drugs, studies have shown that the benefits of anticonvulsant therapy often outweigh the risks. Nevertheless, timely consultation with a psychiatrist is invaluable in the care of these patients, particularly those with multiple risk factors, as in the index case. The risk of suicidality should be balanced with the risk of uncontrolled seizures. Specifically, in the case of levetiracetam, it is important to be aware of the subgroup of individuals with prior severe psychiatric illness, a history of traumatic brain injury, or a history of substance use disorder who might be at an increased risk of developing suicide-related behavior and suicidal ideations once levetiracetam is started.