Would an electroencephalogram (EEG) be helpful in a patient with altered mental status and lethargy, with a history of suicide attempts, currently on sertraline (selective serotonin reuptake inhibitor)?

From the Guidelines

An electroencephalogram (EEG) is recommended in the evaluation of a patient with altered mental status and lethargy, especially with a history of suicide attempts and current use of sertraline, as it can help identify potential causes such as seizures, encephalopathy, or medication effects. The patient's presentation of altered mental status and lethargy, coupled with a history of suicide attempts, raises concerns for possible sertraline overdose or serotonin syndrome, conditions that can be associated with abnormal brain electrical activity detectable by EEG 1. EEG can detect diffuse slowing in encephalopathy or specific patterns in drug toxicity, which would be crucial in guiding treatment decisions.

Given the potential for sertraline to cause neurological symptoms, especially in overdose situations, an EEG becomes a valuable tool in the comprehensive evaluation of this patient. The test can help rule out other neurological causes of altered mental status that require different management approaches. It is also important to consider that the diagnosis of delirium, which can present with altered mental status, is a medical emergency, and early detection and accurate diagnosis are extremely important as mortality in patients may be twice as high if the diagnosis of delirium is missed 1.

Key points to consider in the evaluation and management of this patient include:

• The use of validated assessment scales, such as the Richmond Agitation Sedation Scale and Glasgow Coma Scale, to objectively quantify the severity of symptoms 1.
• The potential for delirium, which is a defined and diagnosable medical condition that includes inattention as a cardinal feature and may fluctuate over the course of the day with lucid intervals 1.
• The importance of identifying and treating the underlying cause of altered mental status, which could include infection, intoxication, or withdrawal, among others 1.
• The role of psychiatric consultation and screening tools, such as the Confusion Assessment Method (CAM), in assessing for delirium 1.

In the context of real-life clinical medicine, prioritizing the patient's safety and promptly identifying the cause of altered mental status are paramount. Therefore, an EEG, as part of a comprehensive evaluation that includes clinical assessment, laboratory studies, and potentially neuroimaging, is a recommended step in the management of this patient.

From the Research

Altered Mental Status and Lethargy

• In a patient with altered mental status and lethargy, an electroencephalogram (EEG) can be a helpful diagnostic tool, particularly in detecting subclinical seizures or nonconvulsive status epilepticus (NCSE) 2.
• The use of EEG in such cases can provide valuable information about the patient's brain activity and help identify potential underlying causes of their altered mental status.

History of Suicide Attempts and Sertraline Use

• The patient's history of suicide attempts is a significant concern, and the use of sertraline (a selective serotonin reuptake inhibitor) may be relevant in this context 3.
• Research suggests that SSRIs like sertraline may increase suicidal behavior in some individuals, particularly by energizing depressed patients to act on preexisting suicidal thoughts or by inducing akathisia with associated self-destructive impulses 3.
• However, it is essential to note that the relationship between SSRIs and suicidal behavior is complex, and more research is needed to fully understand this association.

EEG Correlates of Suicide Ideation and Attempt

• A study on resting state EEG correlates of suicide ideation and attempt found that imbalances in frontal and left temporal brain regions might reflect abnormal activation and correlate with psychological distress 4.
• The study suggests that EEG might play a key role in identifying individuals at high risk of suicide, although more research is needed to develop intelligent algorithms for the automated detection of high-risk EEG anomalies.

Clinical Considerations

• In patients with a history of suicide attempts, close monitoring and guidance are crucial, particularly when changing antidepressants or reducing benzodiazepines 5.
• The use of mood stabilizers, such as lithium, may be beneficial in reducing the risk of suicidal behavior, especially in patients with a history of suicide attempts 6, 5, 3.