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Epilepsy is often seen as a benign condition, but in reality nothing could be further from the truth. It has a high morbidity and carries an increased risk of premature mortality, consistently seen in many studies.1 Increased mortality in epilepsy is an important part of its burden; some aspects of it are, however, baffling, as the reasons for it are not entirely clear. When death occurs in people with recent onset of epilepsy, it is often due to the same condition which caused the epilepsy. In people with chronic epilepsy, sudden unexpected death in epilepsy is a common cause, at least in high-income countries. These two situations, however, do not explain the whole story. Many studies have been carried out in refractory populations, and as a result of this it is often stated that the risk is related to the activity of epilepsy; that is, people with active seizures are at a higher risk. A recent study in an incident population in which most people are in remission, however, suggests that there is still an increased risk, even when seizures are long fully controlled.2 This is difficult to square with current knowledge and makes this issue intriguing. The jury is therefore still out. Any contributions that will lead to the elucidation of this risk so that preventive measure can be put into place are welcomed. Leone et al3 (see page 924) add some further pieces to the puzzle of mortality in epilepsy. They report on the mortality in people with epilepsy who participated in a study in which they were randomised either to early treatment, at the time of the first seizure, or to delayed treatment, waiting until a recurrence had occurred to start treatment. They have now been followed up over a 20-year period. An early report suggested that there was no difference in outcome in regards to seizure control in the two groups.4 From this current report, it also seems that early or delayed treatment made no difference to the risk of mortality. This in itself is not surprising but nevertheless reassuring. One very interesting finding of the study was that the risk of premature death was increased in those who had a clear aetiological factor for the epilepsy, independent of the treatment group. These aetiological factors, although probably responsible for the epilepsy, seem not to be directly responsible for the death of the participants.
Psychiatric comorbidity is increased in people with epilepsy, and this is well known. Less known is the increase in somatic comorbidity.5 Epilepsy seems to carry an increased risk of vascular disorders, gastrointestinal problems, migraine, hypertension, dementia, cancer and obstructive sleep apnoea. It is intriguing to speculate about the role of these comorbidities in this increase in premature mortality, particularly if these are due to a common genetic predisposition. Further studies to clarify the whole spectrum of risk are urgently needed. At this point, one can clearly say that reducing morbidity and mortality in epilepsy should be an important aim of management.
Competing interests None.
Provenance and peer review Commissioned; not externally peer reviewed.