Verrotti et al depression remains a risk factor strictly for women but not for men (Kalinin et al 2005a). Adolescence Adolescence is a period marked by profound biological, social, and psychological developmental changes (Kaplan et al 1998). Depression and other disorders are common problems among adolescents (Baker 2006), but are underdiagnosed. Signs of depression are often dismissed as “normal” reactions in this age group (Lagges et al 2003) and depressed adolescents may appear irritated, bored, and impulsive (Brent et al 2002). Depression is much more common in adolescents with chronic disease, such as diabetes and epilepsy (Brent et al 2002; Suris et al 1996). A greater proportion of girls with chronic illness report feeling sad, having suicidal thoughts, and other symptoms of depression. In contrast, no signiﬁcant differences were seen between boys with chronic illness and controls, although there was a trend toward having more emotional problems (Suris et al 1996). Many studies showed that onset of epilepsy in a period of psychosocial maturation is of greater importance than a long-standing illness, although the precise mechanisms lead- ing to the increased suicide risk are not known and might well be multifactorial (Nilsson et al 2002). Additional risk factors Axis I disorders are a primary risk factor for suicide, although additional risk factors must be considered when conducting a suicide assessment. General risk factors for suicide include amily issues, physical health, personality, life stress, previous suicidal behavior, and access to ﬁrearms or other destructive means (Obfaunwa et al 1994). A family history of suicidal behavior increases the risk of suicide, and the risk increases if coupled with a family history of affective disorder or substance abuse (Moscicki 1997). Care should be taken to assess an individual’s perception of health issues, and how it might inﬂuence thoughts about the future. Individuals with epilepsy may be affected by risk factors such as an increase in unemployment rates and ﬁnan- cial stress, and possibly increased family stress as a result of complications associated with a chronic medical condition (Robertson 1997; Jones et al 2003; Caplan et al 2005). Table 1 summarizes the risk factors in epileptic patients. Assessment At the time of the initial diagnostic evaluation, the physi- cian who is managing the epileptic patient should make 368 Table 1 Risk factors for death caused by suicide in eplieptic patients -Psychiatric comorbidity Axis I Major depression Affective disorders Psychoses Substance abuse Axis II Personality disorders -Cognitive deterioration -Antiepileptic drugs Phenobarbital -Types of seizures Temporal lobe epilepsy Simple partial seizures Primary generalized seizures Secondary generalized seizures -Frequency of seizures -Early age at epilepsy onset a psychiatric and psychosocial assessment to identify the patient’s risk for suicide. This approach enables the physi- cian to assess the effect of epilepsy on the patient and to detect psychiatric disorder. Effective treatment options include both somatic and non somatic therapies as well as combinations thereof. Interventions include medications, referral to a psycholo- gist or psychiatrist, or even hospitalization. If appropriate intervention can be introduced, suicide rates may be signiﬁ- cantly reduced (Jones et al 2003). Greater attention is needed to other potentially self- injurious behaviors such as willful noncompliance with antiepileptic drug (AED) therapy and participation in activities that might be considered dangerous for those with active epilepsy (eg, swimming, climbing) (Jones et al 2003). A number of methods can be used to screen for suicide risk factors. Jones and colleagues (2003) report a useful instrument developed to assess individuals for psychiatric disorders and suicidality called MINI (Mini-International Neuropsychiatric Interview). The MINI module includes a systematic and useful series of questions that could be included in a clinical interview when screening for depres- sion and psychiatric comorbidity in a busy clinical setting. MINI has a practical scoring system to help quantify cur- rent suicide risk and may prove useful in determining the intervention required. Further self-report measures include the Beck Depression Inventory, which contains suicidal ideation-related items (eg, question 9: “suicide thoughts and wishes”) that may prove useful for rapid screening. Neuropsychiatric Disease and Treatment 2008:4(2)