Gail S Bell

Publications of Gail S Bell

• Non-randomized open trial of eicosapentaenoic acid (EPA), an omega-3 fatty acid, in ten people with chronic epilepsy.

  Authors: Alan W C Yuen, Dominique Flugel, Annkathrin Poepel, Gail S Bell, Janet L Peacock, Josemir W Sander

  Epilepsy & behavior : E&B. 02/2012; 23(3):370-2.

  This is a non-randomized open assessment of eicosapentaenoic acid (EPA) supplementation in ten people (five males) with refractory focal seizures. Each received 1000mg of EPA daily for 3months. SixThis is a non-randomized open assessment of eicosapentaenoic acid (EPA) supplementation in ten people (five males) with refractory focal seizures. Each received 1000mg of EPA daily for 3months. Six people had fewer seizures during the supplementation period compared with baseline (range 12 to 59% reduction) and one other person had markedly reduced seizure severity. The mean reduction in seizure frequency was 16% (95% CI - 10% to 35%, p=0.26). With the small number of participants and open nature of the study, interpretation of the results is difficult, but a possible weak effect of EPA on seizures cannot be discounted. Further examination of EPA supplementation should be undertaken with larger numbers of people in controlled trials. Higher doses and longer duration of treatment should be considered.

• The long-term outcome of adult epilepsy surgery, patterns of seizure remission, and relapse: a cohort study.

  Authors: Jane de Tisi, Gail S Bell, Janet L Peacock, Andrew W McEvoy, William F J Harkness, Josemir W Sander, John S Duncan

  Lancet. 10/2011; 378(9800):1388-95.

  Surgery is increasingly used as treatment for refractory focal epilepsy; however, few rigorous reports of long-term outcome exist. We did this study to identify long-term outcome of epilepsy surgerySurgery is increasingly used as treatment for refractory focal epilepsy; however, few rigorous reports of long-term outcome exist. We did this study to identify long-term outcome of epilepsy surgery in adults by establishing patterns of seizure remission and relapse after surgery. We report long-term outcome of surgery for epilepsy in 615 adults (497 anterior temporal resections, 40 temporal lesionectomies, 40 extratemporal lesionectomies, 20 extratemporal resections, 11 hemispherectomies, and seven palliative procedures [corpus callosotomy, subpial transection]), with prospective annual follow-up for a median of 8 years (range 1-19). We used Kaplan-Meier survival analysis to estimate time to first seizure, and investigated patterns of seizure outcome. We used survival methods to estimate that 52% (95% CI 48-56) of patients remained seizure free (apart from simple partial seizures [SPS]) at 5 years after surgery, and 47% (42-51) at 10 years. Patients who had extratemporal resections were more likely to have seizure recurrence than were those who had anterior temporal resections (hazard ratio [HR] 2·0, 1·1-3·6; p=0·02); whereas for those having lesionectomies, no difference from anterior lobe resection was recorded. Those with SPS in the first 2 years after temporal lobe surgery had a greater chance of subsequent seizures with impaired awareness than did those with no SPS (2·4, 1·5-3·9). Relapse was less likely the longer a person was seizure free and, conversely, remission was less likely the longer seizures continued. In 18 (19%) of 93 people, late remission was associated with introduction of a previously untried antiepileptic drug. 104 of 365 (28%) seizure-free individuals had discontinued drugs at latest follow-up. Neurosurgical treatment is appealing for selected people with refractory focal epilepsy. Our data provide realistic expectations and indicate the scope for further improvements in presurgical assessment and surgical treatment of people with chronic epilepsy. UK Department of Health National Institute for Health Research (NIHR) Biomedical Research Centres funding scheme, Epilepsy Society, Dr Marvin Weil Epilepsy Research Fund.

• How refractory is refractory epilepsy? Patterns of relapse and remission in people with refractory epilepsy.

  Authors: Aidan Neligan, Gail S Bell, Josemir W Sander, Simon D Shorvon

  Epilepsy research. 07/2011; 96(3):225-30.

  Outcome studies in people with epilepsy have largely focused on the prognosis in the early stages and factors predictive of early remission. Few studies have examined prognosis in chronic refractoryOutcome studies in people with epilepsy have largely focused on the prognosis in the early stages and factors predictive of early remission. Few studies have examined prognosis in chronic refractory epilepsy. We determined the pattern of remission and relapse of epilepsy in a cohort of people with refractory epilepsy (seizures in the past two years, at least five years after onset and who have been treated with at least 2 appropriate antiepileptic drugs during that time) to investigate whether any clinical or demographic features are predictive of seizure patterns. Seizure patterns were defined as intermittent (at least one previous period of remission of two or more years with a subsequent relapse) or continuous (no periods of remission of two years or more since seizure onset). We correlated clinical variables with these patterns. We devised a prognostic model summarising patterns of remission and relapse over time in epilepsy. 290 people were recruited, of whom 70% had a continuous pattern of seizures with the remaining 30% having an intermittent pattern. The only clinical variables which significantly differed between the two groups were a higher total number of antiepileptic drugs taken by those in the continuous group (P=0.01) and fewer seizures in the previous year in the intermittent group (P<0.001). A prognostic model of epilepsy is proposed. There is considerable heterogeneity in long-term seizure patterns in people who do not enter long-term remission in the early years after diagnosis.

• The long-term retention of zonisamide in a large cohort of people with epilepsy at a tertiary referral centre.

  Authors: Claudia B Catarino, Emanuele Bartolini, Gail S Bell, Alan W C Yuen, John S Duncan, Josemir W Sander

  Epilepsy research. 05/2011; 96(1-2):39-44.

  Zonisamide (ZNS) is an antiepileptic drug (AED) with multiple putative mechanisms of action. It is chemically unrelated to other AEDs. It has been available in Japan since 1989 but was only licensedZonisamide (ZNS) is an antiepileptic drug (AED) with multiple putative mechanisms of action. It is chemically unrelated to other AEDs. It has been available in Japan since 1989 but was only licensed in Europe in 2005. Its efficacy and tolerability have been shown in several randomised controlled trials, but large studies on long-term performance in Western clinical practice are scarce. We assessed a large cohort of consecutive people who started ZNS at a tertiary epilepsy referral centre, from June 2005 to July 2009. Forty-six percent of the 417 people included were still taking ZNS at last follow-up, with an estimated retention rate at three years of 30%. Almost one third of the population reported a period of improvement in terms of seizure reduction of at least six months duration whilst on ZNS. Sixteen people became seizure free for at least six months and seven of these were seizure free for one year or more. Adverse events occurred in 58%, frequently CNS-related. People on three or more AEDs and people starting zonisamide at 25mg daily rather than 50mg or more, were more likely to discontinue ZNS. Retention rates for ZNS were similar to those previously reported, and comparable to lamotrigine, topiramate, pregabalin, higher than gabapentin, and lower than levetiracetam.

• The long-term risk of premature mortality in people with epilepsy.

  Authors: Aidan Neligan, Gail S Bell, Anthony L Johnson, David M Goodridge, Simon D Shorvon, Josemir W Sander

  Brain : a journal of neurology. 02/2011; 134(Pt 2):388-95.

  People with epilepsy have an increased risk of premature death. The risk is highest soon after onset of seizures. We report the findings of a long-term follow-up population-based study of people withPeople with epilepsy have an increased risk of premature death. The risk is highest soon after onset of seizures. We report the findings of a long-term follow-up population-based study of people with epilepsy with regards to premature mortality. The National General Practice Study of Epilepsy is a prospective study flagged at the National Health Service Information Centre in the UK. Over 1000 people with new onset seizures were followed from the mid 1980s until April 2009. Of these, 564 people were classified at 6 months as having definite epileptic seizures, 228 as having possible epileptic seizures and 220 as having febrile seizures. The remainder were excluded (n=104 because of an unknown prior diagnosis of epilepsy or neonatal seizures) or classified as not having epilepsy (n=79). At median follow-up of 22.8 years there had been 301 deaths in the cohort; 300 of these were in people with definite or possible seizures. Death certificates were obtained for all but three of those who died. The overall standardized mortality ratio for those with definite or possible epilepsy was 2.2 (95% confidence interval 1.97-2.47), and was higher in those with definite seizures (2.6). In those who were alive at 20 years follow-up, the standardized mortality ratio in the subsequent years remained significantly elevated (2.2, 95% confidence interval 1.6-3.2). Pneumonia (standardized mortality ratio 6.6, 95% confidence incidence 5.1, 8.4) was a common cause of death with a consistently elevated standardized mortality ratio throughout follow-up. The standardized mortality ratio for ischaemic heart disease was significantly elevated for the first time in the last 5 years of follow-up (3.3, 95% confidence interval 1.6-7.0). Few people died from epilepsy-related causes. The risk of premature death remains significantly elevated at 20-25 years after the index seizure despite most of the cohort being in terminal remission (defined as 5 years or more seizure-free, on or off anti-epileptic medication) at the last follow-up. Further studies are needed to explore the reasons for this long-term increase in premature mortality.

• Multicultural challenges in epilepsy.

  Authors: Emanuele Bartolini, Gail S Bell, Josemir W Sander

  Epilepsy & behavior : E&B. 02/2011; 20(3):428-34.

  Epilepsy is a common neurological condition throughout the world. Its care involves medical expertise, but may also bring different cultural challenges. We discuss clinical, social and psychologicalEpilepsy is a common neurological condition throughout the world. Its care involves medical expertise, but may also bring different cultural challenges. We discuss clinical, social and psychological outcomes in different cultural settings. We point out differences and similarities in epilepsy epidemiology (etiology and risk factors, prognosis, and natural history), disparities in care and health services, and cultural influences and traditional beliefs, with special respect to practical issues and possible transcultural misunderstandings. We also discuss the relevance of multicultural issues to clinicians working in developed countries.

• Sudden death in epilepsy.

  Authors: Aidan Neligan, Gail S Bell, Josemir W Sander

  BMJ (Clinical research ed.). 01/2011; 343:d7303.

• Temporal trends in the mortality of people with epilepsy: a review.

  Authors: Aidan Neligan, Gail S Bell, Simon D Shorvon, Josemir W Sander

  Epilepsia. 11/2010; 51(11):2241-6.

  It is now generally accepted that people with epilepsy are at increased risk of premature death compared with peers in the general population. It has, however, not been clearly established how thisIt is now generally accepted that people with epilepsy are at increased risk of premature death compared with peers in the general population. It has, however, not been clearly established how this risk changes over time, nor whether mortality rates have been changing over time. We carried out a systematic review: (1) To determine the pattern of change of mortality risk relative to the general population in people with epilepsy in the course of their condition as measured by standardized mortality ratios (SMRs), by reviewing longitudinal prospective cohort studies. (2) To establish whether there have been any changes in reported mortality rates for epilepsy in general populations over time. This was complemented by comparison of SMRs in people with epilepsy in the same types of source populations (population-based, hospital-based, and institutional studies) in different time periods to ascertain any changes in reported mortality rates. The SMR is highest in the initial years after diagnosis and subsequently decreases. There is a suggestion that there may be an increase after 10 years from diagnosis despite the fact that the majority of people in these cohorts are in long-term remission. There is no evidence that either the overall SMR or the mortality rate of people with epilepsy has changed significantly over time. Further population and cohort studies are needed to confirm these findings.

• Effects of AEDs on biomarkers in people with epilepsy: CRP, HbA1c and eGFR.

  Authors: Alan W C Yuen, Gail S Bell, Janet L Peacock, Matthias M Koepp, Philip N Patsalos, Josemir W Sander

  Epilepsy research. 10/2010; 91(2-3):187-92.

  The standardised mortality ratio in people with epilepsy is raised to between 2 and 3 compared with the general population. Some biomarker levels, including higher C-reactive protein (CRP), higherThe standardised mortality ratio in people with epilepsy is raised to between 2 and 3 compared with the general population. Some biomarker levels, including higher C-reactive protein (CRP), higher glycosylated haemoglobin (HbA1c) and lower estimated glomerular filtration rate (eGFR), are associated with an increase risk of premature mortality. These biomarkers were measured in 125 people with refractory epilepsy to estimate the potential effect of antiepileptic drug (AED) use on these markers. Multiple regression analysis showed that valproate (N=50) use was associated with 55% lower mean CRP concentrations and higher mean eGFR values; and phenytoin (N=32) use with 4% lower mean HbA1c values. These potentially represent health markers improved by AEDs. On the other hand, lamotrigine use (N=48) was associated with 13% lower mean eGFR and this may represent a negative effect on a health marker. These preliminary observations clearly require further controlled studies ideally in people on AED monotherapy.

• Antiepileptic medications and the risk of suicide.

  Authors: Aidan Neligan, Gail S Bell, Marco Mula

  JAMA : the journal of the American Medical Association. 08/2010; 304(5):521; author reply 522-3.

• Suicidality in epilepsy and possible effects of antiepileptic drugs.

  Authors: Marco Mula, Gail S Bell, Josemir W Sander

  Current neurology and neuroscience reports. 07/2010; 10(4):327-32.

  Suicide is an important cause of premature death, and people with epilepsy are thought to be at increased risk for suicide. Antiepileptic drugs (AEDs) continue to be the mainstay of epilepsySuicide is an important cause of premature death, and people with epilepsy are thought to be at increased risk for suicide. Antiepileptic drugs (AEDs) continue to be the mainstay of epilepsy treatment, but the benefits of seizure control must be balanced with their psychotropic potential. In recent years, suicidality has been recognized as a complication of several groups of drugs and, most recently, AEDs were implicated in an alert by the US Food and Drug Administration. The risk of suicidal ideation and behavior as side effects of AED treatment is low, and in people with epilepsy, such a risk must be balanced against the risk of not treating the seizures.

• Assessing suicidal risk with antiepileptic drugs.

  Authors: Marco Mula, Gail S Bell, Josemir W Sander

  Neuropsychiatric disease and treatment. 01/2010; 6:613-8.

  Recently, the US Food and Drug Administration issued an alert about an increased risk for suicidality during treatment with antiepileptic drugs (AEDs) for different indications, including epilepsy.Recently, the US Food and Drug Administration issued an alert about an increased risk for suicidality during treatment with antiepileptic drugs (AEDs) for different indications, including epilepsy. We discuss the issue of suicide in epilepsy with special attention to AEDs and the assessment of suicide in people with epilepsy. It has been suggested that early medical treatment with AEDs might potentially reduce suicide risk of people with epilepsy, but it is of great importance that the choice of drug is tailored to the mental state of the patient. The issue of suicidality in epilepsy is likely to represent an example of how the underdiagnosis of psychiatric symptoms, the lack of input from professionals (eg, psychologists, social workers, and psychiatrists), and the delay in an optimized AED therapy may worsen the prognosis of the condition with the occurrence of severe complications such as suicide.

• Seasonality as a risk factor for sudden unexpected death in epilepsy: A study in a large cohort.

  Authors: Gail S Bell, Janet L Peacock, Josemir W Sander

  Epilepsia. 10/2009;

  Summary Purpose: We attempted to establish whether month and season, or lunar phase, are risk factors for sudden unexpected death in epilepsy (SUDEP), as these have all been suggested as potentialSummary Purpose: We attempted to establish whether month and season, or lunar phase, are risk factors for sudden unexpected death in epilepsy (SUDEP), as these have all been suggested as potential risk factors. Methods: We used the dataset of the National Sentinel Clinical Audit of Epilepsy-Related Death; all death certificates of people who died in England and Wales between September 1999 and August 2000 and in which epilepsy was mentioned were reviewed. We identified people who probably died of SUDEP during that time. We compared the number of observed SUDEP cases with those expected according to month of death, season of death, minimum external temperature, mean external temperature, and lunar phase. Results: Of 2,412 deaths, we identified 409 probable SUDEPs. We found no evidence for an association between either mean temperature group or minimum temperature group and SUDEP, although there appeared to be a slight excess of sudden deaths in the coldest (mean temperature) groups. We also found no association between SUDEP and month, season, or lunar phase. Discussion: Some causes of death appear to be related to temperature, but we found no convincing evidence to support a link between temperatures or seasons and sudden unexpected death in epilepsy. It is important to identify risk factors for SUDEP, but it is also important that evidence is established before hypotheses are accepted.

• Pathologic cardiac repolarization in pharmacoresistant epilepsy and its potential role in sudden unexpected death in epilepsy: A case-control study.

  Authors: Rainer Surges, Patrick Adjei, Constantinos Kallis, Joy Erhuero, Catherine A Scott, Gail S Bell, Josemir W Sander, Matthew C Walker

  Epilepsia. 10/2009;

  Summary Purpose: To determine whether abnormal cardiac repolarization and other electrocardiography (ECG) predictors for cardiac mortality occur in epilepsy patients and whether they are associatedSummary Purpose: To determine whether abnormal cardiac repolarization and other electrocardiography (ECG) predictors for cardiac mortality occur in epilepsy patients and whether they are associated with an increased risk for sudden unexpected death in epilepsy (SUDEP). Methods: In a matched-pair case-control study, recordings of adult patients with pharmacoresistant focal epilepsies who died from SUDEP and who had previously had presurgical video-EEG (electroencephalography) telemetry were reviewed. Living controls were matched for age, gender, and date of admission for video-EEG telemetry. Periictal heart rate (HR), corrected QT interval (QTc), postictal HR recovery, HR variability, and cardiac rhythm were assessed. QT dispersion was analyzed with 12-lead ECG. Results: A total of 38 patients (19 per group) had 91 recorded seizures. QTc was prolonged above pathologic upper limits in 9 of 89 seizures and 5 of 38 patients. Nine of 34 patients displayed pathologic QT dispersion. Presence of neither pathologic cardiac repolarization nor other ECG features were specifically associated with SUDEP. SUDEP patients were, however, more likely to lack pathologic cerebral magnetic resonance imaging (MRI) findings, less likely to experience antiepileptic drug reduction during telemetry, and had more secondarily generalized tonic-clonic seizures (SGTCS) per year. Discussion: Our study did not reveal a clear-cut ECG predictor for SUDEP. Pathologic cardiac repolarization is not uncommon in adult patients with pharmacoresistant focal epilepsy and could favor occurrence of fatal tachyarrhythmia as one plausible cause for SUDEP. SGTCS are a risk factor for SUDEP, have, as compared to complex-partial seizures, a greater, unfavorable impact on heart activity, and may thereby additionally compromise cardiac function.

• The long-term retention of pregabalin in a large cohort of patients with epilepsy at a tertiary referral centre.

  Authors: Alan W C Yuen, Rinki Singh, Gail S Bell, Anupam Bhattacharjee, Aidan Neligan, Dominic C Heaney, John S Duncan, Josemir W Sander

  Epilepsy research. 10/2009;

  Pregabalin (PGB) is a new antiepileptic drug (AED) which is a structural, non-functional analogue of gamma-aminobutyric acid. It acts at presynaptic calcium channels to modulate neurotransmitterPregabalin (PGB) is a new antiepileptic drug (AED) which is a structural, non-functional analogue of gamma-aminobutyric acid. It acts at presynaptic calcium channels to modulate neurotransmitter release in the CNS. While the efficacy and tolerability of PGB have been demonstrated in several randomised controlled trials, few studies have addressed long-term outcome in large groups of patients. A cohort of patients attending a tertiary referral centre for epilepsy was identified as having started taking PGB. Patients' data were obtained through medical records. Of 402 patients included, 42% of patients were still taking PGB at last follow-up. The estimated 2.5-year retention rate was 32%. Males appeared more likely to continue on PGB therapy than females. The common adverse experiences (AEs) leading to withdrawal were CNS-related, psychiatric AEs and weight gain. Published retention rates for levetiracetam appear to be higher, and those for gabapentin lower, than the rates estimated for PGB.

• Changes in knowledge, attitude, and practice of people with epilepsy and their families after an intervention in rural China.

  Authors: Wenzhi Wang, Donghai Zhao, Jianzhong Wu, Taiping Wang, Xiuying Dai, Guangyu Ma, Bin Yang, Chenglin Yuan, Gail S Bell, Hanneke M de Boer, Leonid L Prilipko, Ley Sander

  Epilepsy & behavior : E&B. 08/2009;

  To evaluate the effectiveness of a combined intervention on knowledge, attitude, and practice (KAP) of people with epilepsy and their families in rural areas of China, random samples of people withTo evaluate the effectiveness of a combined intervention on knowledge, attitude, and practice (KAP) of people with epilepsy and their families in rural areas of China, random samples of people with epilepsy and their family members from the intervention populations completed questionnaires prior to the intervention (2002, N=975) and 2years later (N=950). There was no significant difference in important demographic variables between the two samples. KAP levels of patients and their family members improved over the study period. Worry about seizures, discrimination, and medical costs are the principal factors in patients' psychological burden. Psychological burden and inability to concentrate at work are the main influences of the disease on family members. Reduction of the psychological burden of patients and their family members is a significant aspect of treatment to which more attention should be paid in similar future interventions.

• Suicide in people with epilepsy: How great is the risk?

  Authors: Gail S Bell, Athanasios Gaitatzis, Catherine L Bell, Anthony L Johnson, Josemir W Sander

  Epilepsia. 06/2009;

  Summary Purpose: Suicide is more common in populations with epilepsy, but estimates vary concerning the magnitude of the risk. We aimed to estimate the risk using meta-analysis. Methods: A literatureSummary Purpose: Suicide is more common in populations with epilepsy, but estimates vary concerning the magnitude of the risk. We aimed to estimate the risk using meta-analysis. Methods: A literature search identified 74 articles (76 cohorts of people with epilepsy) in whom the number of deaths by suicide in people with epilepsy and the number of person-years at risk could be estimated. Standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated for each cohort, for groups of cohorts, and for the total population. Results: The overall SMR was 3.3 (95% CI 2.8-3.7) based on 190 observed deaths by suicide compared with 58.4 expected. The SMR was significantly increased in people with incident or newly diagnosed epilepsy in the community (SMR 2.1), in populations with mixed prevalence and incidence cases (SMR 3.6), in those with prevalent epilepsy (SMR 4.8), in people in institutions (SMR 4.6), in people seen in tertiary care clinics (SMR 2.28), in people with temporal lobe epilepsy (SMR 6.6), in those following temporal lobe excision (SMR 13.9), and following other forms of epilepsy surgery (SMR 6.4). The SMR was significantly low overall in two community-based studies of people with epilepsy and developmental disability. Discussion: We confirm that the risk of suicide is increased in most populations of people with epilepsy. Psychiatric comorbidity has been demonstrated to be a risk factor for suicide in the general population and in people with epilepsy, and such comorbidity should thus be identified and treated.

• Suicide and epilepsy.

  Authors: Gail S Bell, Josemir W Sander

  Current opinion in neurology. 05/2009; 22(2):174-8.

  PURPOSE OF REVIEW: For many years, it has been accepted that suicide may be more common in people with epilepsy. Recent studies have investigated risk factors. RECENT FINDINGS: Studies have shownPURPOSE OF REVIEW: For many years, it has been accepted that suicide may be more common in people with epilepsy. Recent studies have investigated risk factors. RECENT FINDINGS: Studies have shown that a history of psychiatric disease increases the risk of suicide in a person with epilepsy but have also shown that the risk of suicide in people with epilepsy is increased in the absence of a psychiatric history. People with epilepsy may have undiagnosed and untreated psychiatric illness, and depression (both reactive and endogenous) may occur. Studies have suggested that the relationship between seizures and depression or suicidal behaviour may be bidirectional, and both major depression and attempted suicide increase the risk of developing seizures. Forced normalization and postictal psychosis may also contribute to suicidal behaviour. Antiepileptic drugs have been implicated in causing psychiatric adverse effects and suicidal behaviour. SUMMARY: It is important to take an holistic approach when evaluating and monitoring people with epilepsy. Clinicians should screen for depression and treat appropriately. The choice of which antiepileptic drug to use may also be influenced by the presence of depression or suicidal ideation.

• Suicidality in People Taking Antiepileptic Drugs: What is the Evidence?

  Authors: Gail S Bell, Marco Mula, Josemir W Sander

  CNS drugs. 02/2009; 23(4):281-92.

  Suicide is an important cause of premature death. In the general population, most people who commit suicide have a psychiatric problem at the time. People with epilepsy are thought to be at increasedSuicide is an important cause of premature death. In the general population, most people who commit suicide have a psychiatric problem at the time. People with epilepsy are thought to be at increased risk from suicide and suicidality (suicidal ideation or behaviour). Standardized mortality ratios estimated for suicide in people with epilepsy are usually between 3 and 5. Risk factors for suicide in people with epilepsy have been suggested, including early age of onset of seizures, temporal lobe epilepsy, severe seizures and recent control of seizures. Psychiatric co-morbidity also seems to be an important factor in people with epilepsy who commit suicide. In recent years, suicidality has been recognized as a complication of several groups of drugs and, most recently, antiepileptic drugs (AEDs) have been implicated. The US FDA performed a meta-analysis of 199 placebo-controlled studies of 11 AEDs used for seizure control, psychiatric or 'other' indications. There were four completed suicides in those taking AEDs and none in those taking placebo. The odds ratio for suicidal behaviour or ideation was 1.8 (95% CI 1.24, 2.66), suggesting that people taking AEDs are more at risk than those taking placebo. The odds ratio was significantly raised for people taking AEDs for epilepsy, but not for the other indications. AEDs may affect mood by means of several mechanisms. In people with epilepsy, however, the concept of forced normalization (or alternative psychosis) may also play a part. In this situation, control of seizures (by AEDs or epilepsy surgery) may alternate with psychotic features or, less commonly, depression, although this is not fully understood. The risk of suicidal ideation and behaviour as adverse effects of AED treatment, although increased, seems low. As a result of the FDA's alert clinicians are supposed to inform patients and their families of this increased risk but it is important to place it in a proper perspective. Some people with epilepsy are more likely to develop psychiatric adverse effects with any AEDs, and these people should be followed closely whenever a new AED is introduced. Nonetheless, in people with epilepsy the risk of suicidality associated with AEDs needs to be balanced against the risk of not treating the seizures. In fact, the risk of stopping AEDs or refusing to start AEDs for the control of a seizure disorder may be significantly worse and may result in serious harm, including death of the patient.

• Global campaign against epilepsy: assessment of a demonstration project in rural China.

  Authors: Wenzhi Wang, Jianzhong Wu, Xiuying Dai, Guangyu Ma, Bin Yang, Taiping Wang, Chenglin Yuan, Ding Ding, Zhen Hong, Patrick Kwan, Gail S Bell, Leonid L Prilipko, Hanneke M de Boer, Josemir W Sander

  Bulletin of the World Health Organization. 01/2009; 86(12):964-9.

  OBJECTIVE: The Global Campaign Against Epilepsy demonstration project in rural China aimed: to reduce the treatment gap and morbidity of people with epilepsy by using community-level interventions;OBJECTIVE: The Global Campaign Against Epilepsy demonstration project in rural China aimed: to reduce the treatment gap and morbidity of people with epilepsy by using community-level interventions; to train and educate health professionals; to dispel stigma; to identify potential for prevention and to develop models of integration of epilepsy control into the local health systems. We report the overall results of the demonstration project, focusing on the prevalence and the change in the treatment gap of epilepsy after an intervention. METHODS: Door-to-door epidemiological surveys were carried out before, and 6 months after the end of, an intervention project for epilepsy in rural settings in five provinces of China. The intervention consisted of a treatment programme available to patients without prior appropriate treatment and a public health educational programme about epilepsy. The sampled population in the second survey was 51 644 people. FINDINGS: In the second survey, epilepsy was confirmed in 320 people, yielding a lifetime prevalence of 6.2/1000 and a prevalence of active epilepsy of 4.5/1000. The lifetime prevalence and prevalence of active epilepsy in the first survey were 7.0/1000 and 4.6/1000, respectively. The treatment gap of active epilepsy in the second survey was 49.8%, 12.8 percentage points lower than that of the first survey (62.6%). CONCLUSION: The results of this study suggest that the intervention measures used were possibly effective and evidently feasible in rural China, contributing to a decrease in the treatment gap of epilepsy.