Mood disorders and suicide: preliminary toxicologic findings on psychiatric therapeutic compliance

Introduction. Suicide is one of the leading causes of death today, and among all psychiatric disorders, mood disorders are one of the main risk factors. It is well known and proven that suicides are very common among people undergoing treatment and prescribed psychiatric medication. So far, however, there have only been a few studies dealing with this particular phenomenon. For this reason a study was carried out to investigate the extent to which patients with mood disorders who were undergoing pharmacological treatment were complying with the therapy at the time of their suicide. Material and methods. All individual who died by suicide and were autopsied at the Institute of Forensic Medicine of Milan in the last 10 years and simultaneously suffered from Major Depressive Disorder (MDD) or Bipolar Disorder (BD) were retrospectively extrapolated. After that, only those patients for whom it was possible to obtain health records on the last and ongoing drug therapy prescribed were selected. This information was retrieved from hospitals, territorial mental health centers or private psychiatrists. Finally, blood and urine samples that had been taken at autopsies were subjected to toxicological analysis and the results compared with the prescribed therapy. Results. A total of 22 people (11 men and 11 women) aged between 28 and 83 years, were included in the study, 12 with depression and 10 with bipolar disorder. Fourteen cases (63.5%) were people treated as hospital outpatients or inpatients, 5 (23%) were treated in territorial mental health centers and finally 3 (13.5%) by private psychiatrists. The toxicological analysis revealed that only 6 cases (27%) showed a qualitative match with the prescribed medication. In 5 cases (22.7 %) the medication was only partially complied with and in 11 cases (50 %) it was not complied with at all. And even when medication was present, the value was often below the therapeutic range. Overall, more than 70 % of the test subjects adhered to their medication only partially or not at all. This applied to all drug classes, especially benzodiazepines, antidepressants, anxiolytics, antipsychotics and neuroleptics. The post-mortem toxicological analyses also revealed in some cases ethyl alcohol in their blood or traces of illicit drugs or unprescribed medications. Conclusions. It is clear that a toxicologic examination is essential in all psychiatric deceased in general and even more so in suicide cases, as it may demonstrate a lack of compliance. As treatment adherence is considered as a key factor in reducing the risk of suicide, the observed findings inevitably raises relevant clinical questions. Against this background, prospective monitoring of post-mortem medication levels in suicidal individuals and synergistic collaboration between clinicians and forensic pathologists could help to evaluate the effectiveness of specific medical interventions, highlight existing critical problems and develop new approaches to suicide prevention.