Mortality, suicidality and deliberate self-harm in functional seizures: systematic review, age-based, sex-based and region-based meta-analyses

Introduction Mortality rates vary among people with functional seizures (FSs), whether they have comorbid epilepsy or not, potentially owing to higher rates of associated psychiatric comorbidities and deliberate self-harm. We systematically reviewed and meta-analysed studies to derive mortality and suicidality prevalence in people with FS. Methods We deposited our protocol with PROSPERO. We performed a systematic review of the literature across 12 databases, including all studies reporting on mortality, suicidality and deliberate self-harm in people with FS. Meta-analysis was used to define the pooled prevalence of the outcomes, ORs and 95% CIs. The sensitivity analysis included group comparison and meta-regression. Results We included 80 studies, of which 65 were eligible for quantitative synthesis (subjects=9650). The pooled prevalence of previous suicide attempts was 23% (95% CI 19% to 27%), with lower suicide attempt rates in the Eastern Mediterranean and Western Pacific regions compared with Africa, the Americas and Europe (p value for subgroup differences <0.001). The pooled prevalence of reported suicidal ideation was 26% (95% CI 16% to 36%) and for self-harm was 22% (95% CI 16% to 30%). Compared with people with only epileptic seizures, people with only FS disclosed more suicide attempts (OR=3.07, 95% CI 1.81 to 5.19) and higher rates of suicidal ideation (OR=1.85, 95% CI 1.12 to 3.07). Females reported more past suicide attempts than males (OR=2.19, 95% CI 1.01 to 4.73). Conclusions Around one-quarter of people with FS report previous suicide attempts, current suicidal thoughts and/or deliberate self-harmful behaviour, in addition to greater risks of suicide-related death. Screening strategies and targeted psychotherapeutic interventions are needed globally with appropriate cultural contextualisation. PROSPERO registration number CRD42022353999.