Toxicology findings in suicides: concentrations of ethanol and other drugs in femoral blood in victims of hanging and poisoning in relation to age and gender of the deceased. J Forensic Leg Med. 2013;20:842-847. [PMID: 24112333 DOI: 10.1016/j.jflm.2013.06.027]

Fatal Intoxications with Zopiclone-A Cause for Concern?

INTRODUCTION

Zopiclone, a controlled substance prescribed for insomnia, has become a common toxicological finding in forensic autopsy cases. This study investigated the role and extent of zopiclone use in fatal intoxications in Sweden.

METHODS

All forensic autopsy cases positive for zopiclone in femoral blood during 2012-2020 were selected. Among these cases, fatalities caused by intoxication according to the cause of death certificates issued by the forensic pathologist were identified. Intoxications where zopiclone contributed to the cause of death were included in the study. The Swedish Prescribed Drug Register was utilized to examine whether the included cases were prescribed zopiclone or not.

RESULTS

In total 7320 fatal intoxications underwent a forensic autopsy during the study period, 573 of them were caused by zopiclone. Among the zopiclone fatalities, 87% (n = 494) had a prescription for zopiclone, and 8% (n = 43) were monointoxications. Most fatalities, 62% (n = 354) were suicides, and zopiclone was involved in about 17% (n = 354) of all intoxication suicides in Sweden. Women were significantly (p < 0.01) overrepresented in suicides with zopiclone, comprising 56% (n = 291) of fatalities. The median age was 55 years among zopiclone intoxications compared with 44 years amongst all fatal intoxications.

CONCLUSION

This study demonstrates that the toxicity of zopiclone can be lethal both in combination with other substances and on its own. Most individuals dying in fatal zopiclone intoxications were prescribed zopiclone, which potentially indicates that a more restrictive prescribing rate could prevent future intoxication deaths, especially when caring for patients with an increased suicide risk.

A model of evaluative opinion to encourage greater transparency and justification of interpretation in postmortem forensic toxicology

Over the past decades, the calls to improve the robustness of interpretation in forensic science have increased in magnitude. Forensic toxicology has seen limited progress in this regard. In this work, we propose a transparent interpretive pathway for use in postmortem forensic toxicology cases. This process allows the selection of the interpretive methodology based on the amount of previous information that is available for the drug(s) in question. One approach is an assessment of various pharmacological and circumstantial considerations resulting in a toxicological significance score (TSS), which is particularly useful in situations where limited information about a drug is available. When there is a robust amount of case data available, then a probabilistic approach, through the evaluation of likelihood ratios by the forensic toxicologist and of prior probabilities by the fact finder, is utilized. This methodology provides a transparent means of making an interpretive decision on the role of a drug in the cause of death. This will allow the field of forensic toxicology to take a step forward in using best practice in evaluative reporting, a tool already used by many other forensic science disciplines.

Ultrasensitive determination of 10 phenothiazine derivatives and their enantiomers in biological fluids by capillary electrophoresis with contactless conductivity detection

In this study, a simple, rapid, and ultrasensitive technique was developed to identify five pairs of phenothiazine drugs by using ultrasound-enhanced and surfactant-assisted dispersive liquid-liquid microextraction (UESA-DLLME), field-amplified sample injection with capillary electrophoresis (FASI-CE), and capacitively coupled capacitively coupled contactless conductivity detection (C4D). During the CE separation process, UESA-DLLME was used for sample clean-up and offline concentration, and FASI-CE was used for the online concentration of phenothiazine enantiomers. At baseline, the five pairs of phenothiazine enantiomer drugs required 18 min for separation. UESA-DLLME was then used to extract 0.01 mM Tween 80 at pH 10 from a sample solution (extraction solvent, 100 mL of dichloromethane). Subsequently, FASI was used to stack the sample solution (buffer, 30 mM 2-(N-morpholino)ethanesulfonic acid/aspartic acid, additive 4 mM hydroxypropyl-γ-cyclodextrin, pH 2.5), and C4D was used for signal detection (amplitude, 2 Vpp; frequency, 400 kHz). The results indicated that the linear range for quantifying all analyte enantiomers was 1.0-150 nM, with a coefficient of determination exceeding 0.99. In addition, the relative standard deviations in the migration time and peak areas for the 10 analytes were less than 3.2% and 7.2%, respectively. The proposed system has a limit of detection (LOD) for the 10 analytes at a signal-to-noise ratio of 3, ranging from 0.24 to 0.28 nM. The sensitivity enhancement, which compares the LOD0 (limit of detection in the normal method) to LOD1 (limit of detection achieved using the proposed UESA-DLLME-FASI-CE-C4D method), varies between approximately 1200 and 2000 for the 10 analytes. Analysis of the 10 separated analytes spiked in urine and serum samples revealed recovery rates of 88%-106% and 89%-105%, respectively. Therefore, this highly sensitive advanced technique was successfully used to analyze phenothiazine enantiomers in urine and serum samples.

Deliberate Self-Poisoning: Real-Time Characterization of Suicidal Habits and Toxidromes in the Food and Drug Administration Adverse Event Reporting System

INTRODUCTION

Deliberate self-poisoning (DSP) using drugs is the preferred method of suicide at a global level. Its investigation is hampered by limited sample sizes and data reliability. We investigate the role of the US FDA Adverse Event Reporting System (FAERS), a consolidated pharmacovigilance database, in outlining DSP habits and toxidromes.

METHODS

We retrieved cases of 'intentional overdose' and 'poisoning deliberate' from the FAERS (January 2004-December 2021). Using descriptive and disproportionality analyses, we estimated temporal trends, potential risk factors, toxidromes, case-fatality rates and lethal doses (LDs) for the most frequently reported drugs.

RESULTS

We retrieved 42,103 DSP cases (17% fatal). Most cases were submitted in winter. Reports of DSP involved younger people, psychiatric conditions, and alcohol use, compared with non-DSP, and fatality was higher in men and older patients. Suspected drugs were mainly antidepressants, analgesics, and antipsychotics. Multiple drug intake was recorded in more than 50% of the reports, especially analgesics, psychotropics, and cardiovascular agents. The most frequently reported drugs were paracetamol, promethazine, amlodipine, quetiapine, and metformin. We estimated LD25 for paracetamol (150 g).

CONCLUSION

Worldwide coverage of the FAERS complements existing knowledge about DSP and may drive tailored prevention measures to timely address the DSP phenomenon and prevent intentional suicides.

Forensic Aspects of a Fatal Intoxication Involving Acetaminophen, Citalopram and Trazodone: A Case Report

We report the case of a young man, a former heroin addict, found dead at home by the Police Forces in an advanced state of decomposition. Numerous blisters and unpacked tablets of medications were found all over the bed and on the floor of the room. Multiple injuries to the face, left arm and neck of the deceased were noted. The latter damages were attributed to post-mortem dog bites, since no indications of a possible defense against the animal were observed. The autopsy findings were unremarkable. Toxicological investigations performed on peripheral blood and urine by gas chromatography-mass spectrometry (GC-MS) technique showed the presence of acetaminophen, citalopram and trazodone. Combined drug intoxication was proposed as the cause of death since acetaminophen and trazodone concentrations were comparable with the ones found in fatal cases. Moreover, citalopram concentration in peripheral blood was above the toxic range and in accordance with levels found in fatalities due to poly-drug intoxication.

Antipsychotics as a method of suicide: population based follow-up study of suicide in Northern Finland

AIM

This study examined the trend and role of antipsychotics as a method of self-poisoning suicide.

MATERIALS AND METHODS

The basic data covered 483 poisoning suicides, occurring between the years 1988 and 2011, in Northern Finland, of which 178 (115 men, 63 women) were completed using antipsychotics.

RESULTS

During the 23-year follow-up period, second-generation antipsychotics (SGAs) overtook first-generation antipsychotics (FGAs) as a suicide method. Female victims, compared to males, had more commonly used quetiapine (17.5% vs. 6.1%, p = .016), while suicides using promazine were more common in males compared to females (36.5% vs. 22.2%, p = .049). People with unipolar depression had more frequently used SGAs (40.0%) or a combination of SGAs and FGAs (12.5%) than FGAs (19.2%) (p = .019) in their suicides.

CONCLUSION

The use of SGAs in suicides is becoming increasingly common, which calls for further studies.

Antihistamine-related deaths in England: Are the high safety profiles of antihistamines leading to their unsafe use?

AIMS

Antihistamines are routinely taken to control allergic reactions or sedation to induce sleep. There are, however, growing concerns regarding sedating antihistamine misuse. This research aims to evaluate deaths related to antihistamines in England occurring during 2000-2019.

METHODS

Cases reported to the National Programme on Substance Abuse Deaths from England occurring in 2000-2019 with antihistamine detections at postmortem were extracted for analysis.

RESULTS

In total, 1666 antihistamine postmortem detections were identified from 1537 cases. Sedating antihistamines available for purchase under pharmacist supervision but without need for a prescription (pharmacy-only medications) were present in a significant majority of cases (85.2%, P < .01). Despite an increasing trend for antihistamine-related deaths over time, the proportion of deaths where an antihistamine was implicated declined over the same period. Specific concerns with regards to the misuse of these pharmacy-only sedating antihistamines are raised with regards to the significant proportion of cases that were concluded as suicide (20.9%, P < .01), and the high prevalence of their use in combination with other central nervous system depressants (94.8% of cases).

CONCLUSION

This is the first report in over 40 years regarding antihistamine-related mortality from England. The rising trend in sedating antihistamine-related deaths may be contributed to by their increasing availability and the perceived negligible dangers associated with antihistamines, both from the general public and learned professionals. Awareness of the dangerous sedative properties that some antihistamines possess is, however, heightened in individuals deliberately seeking these effects. Urgent review of sedating antihistamines currently assigned under the pharmacy-only classification is needed to achieve antihistamine harm reduction.

Alcohol and cocaine use prior to suspected suicide: Insights from toxicology

INTRODUCTION

This study investigates whether there is a relationship between alcohol and cocaine use in deaths where suicide by self-injury is the suspected cause of death.

METHODS

Adults referred by coroners to the Imperial College London Toxicology Unit for toxicological analysis between 2012 and 2016 were reviewed for inclusion criteria. Those who died by self-injury reasoned to be deliberate were included in the analysis. Femoral blood alcohol concentration (BAC) and presence of cocaine or benzoylecognine (a metabolite of cocaine) in blood and/or urine were tabulated and odds ratios calculated.

RESULTS

A total of 1722 decedents met inclusion criteria. BAC was ≥50 mg/dL in 29% of decedents. Cocaine was detected in 8.4% of cases. The likelihood of testing positive for cocaine increased with BAC and was most frequent between 100 and 199 mg/dL, consistent with moderate to severe intoxication (odds ratio 5.88, 95% confidence interval 3.80, 9.09; P ≤ 0.001) compared to those with BAC <10 mg/dL.

DISCUSSION AND CONCLUSIONS

This study demonstrates a correlation between increasing BAC and likelihood of cocaine use prior to suspected suicide, up to a level consistent with severe intoxication. Cocaine use was found in a high proportion of cases relative to the general population reporting regular use. This pattern of drug and alcohol use has previously been given little attention in suicide prevention strategies and clinical prioritisation.

Male depressive traits in relation to violent suicides or suicide attempts: A systematic review

BACKGROUND

Male sex is a consistently reported risk factor for violent suicide. It has been suggested that this association may be driven by so-called male depression - as operationalized by the Gotland Male Depression Scale (GMDS). The aim of this systematic review was to investigate if males dying by or attempting suicide with violent methods, display symptoms compatible with male depression.

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search of PubMed, Embase and PsycINFO was performed using search terms covering: male sex, violent suicide/suicide attempt, and symptoms of male depression from the GMDS. Subsequently, a qualitative synthesis of studies meeting predefined inclusion criteria was carried out.

RESULTS

A total of 28 studies reporting on 91,933 violent suicides and 113 violent suicide attempts were included in the qualitative synthesis. The suicide/suicide attempt methods reported in these studies were predominantly shooting, hanging or drowning. The only two symptoms from the GMDS that was reported in relation to violent suicides/suicide attempts was overconsumption of alcohol or drugs and suicide attempts in the biological family. No studies had systematically assessed suicide victims or attempters for symptoms of male depression.

LIMITATIONS

Publication-, selection-, and information biases may have affected this review.

CONCLUSIONS

Symptoms of male depression are rarely reported in relation to violent suicides/suicide attempts. The most likely explanation for this finding is that there has been little focus on this potential association. Future studies should address this void.

From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study

Objectives: Several studies have shown mortality and suicide risk in substance use disorders, and autopsy findings with respect to the used substances. However, there seems to be a gap in the knowledge about substances misused in life and at death at the within-person level. Methods: All consecutive, autopsied patients during 1993 to 1997, who had been in contact with the Addiction Centre in Malmö from 1968, were investigated (365 subjects). Drug misuse in the long-term course noted in case records was related to autopsy findings. Self-inflicted death (suicide/undetermined suicide/accidental overdose) was compared with natural death. Results: Benzodiazepine misuse was associated with a high risk of autopsy findings of the substance in suicide and death of undetermined intent. It was also associated among non-misusers, but less so. An alcohol level above 1‰ was found more often in self-inflicted death. Prescription opioids at autopsy were mainly found in self-inflicted death among non-misusers. Heroin misuse was related to overdose. Central nervous system stimulants (CNS-S) and cannabis were rarely found in self-inflicted death among previous misusers. The overlap between depression in life and antidepressants at death was low. Conclusions: Benzodiazepines and alcohol seem to disinhibit suicidal tendencies. Suicide risk among users of cannabis and CNS-S may be related to other risk factors than acute use. Implications for suicide prevention are discussed.

Psychoactive substances in natural and unnatural deaths in Norway and Sweden - a study on victims of suicide and accidents compared with natural deaths in psychiatric patients

BACKGROUND

The extent of post-mortem detection of specific psychoactive drugs may differ between countries, and may greatly influence the national death register's classification of manner and cause of death. The main objective of the present study was to analyse the magnitude and pattern of post-mortem detection of various psychoactive substances by the manner of death (suicide, accidental, undetermined and natural death with a psychiatric diagnosis) in Norway and Sweden.

METHODS

The Cause of Death Registers in Norway and Sweden provided data on 600 deaths in 2008 from each country, of which 200 were registered as suicides, 200 as accidents or undetermined manner of death and 200 as natural deaths in individuals with a diagnosis of mental disorder as the underlying cause of death. We examined death certificates and forensic reports including toxicological analyses.

RESULTS

The detection of psychoactive substances was commonly reported in suicides (66 and 74% in Norway and Sweden respectively), accidents (85 and 66%), undetermined manner of deaths (80% in the Swedish dataset) and in natural deaths with a psychiatric diagnosis (50 and 53%). Ethanol was the most commonly reported substance in the three manners of death, except from opioids being more common in accidental deaths in the Norwegian dataset. In cases of suicide by poisoning, benzodiazepines and z-drugs were the most common substances in both countries. Heroin or morphine was the most commonly reported substance in cases of accidental death by poisoning in the Norwegian dataset, while other opioids dominated the Swedish dataset. Anti-depressants were found in 22% of the suicide cases in the Norwegian dataset and in 29% of suicide cases in the Swedish dataset.

CONCLUSIONS

Psychoactive substances were detected in 66 and 74% of suicides and in 85 and 66% of accidental deaths in the Norwegian and Swedish datasets, respectively. Apart from a higher detection rate of heroin in deaths by accident in Norway than in Sweden, the pattern of detected psychoactive substances was similar in the two countries. Assessment of a suicidal motive may be hampered by the common use of psychoactive substances in suicide victims.

Higher Heart Weight in New Zealand Māori and Pacific Islanders

Heart weight is dependent on sex, age, height, and weight. Although previous autopsy studies showed no differences in heart weight between different ethnic groups, none have examined the New Zealand population of Māori and Pacific Islanders (Polynesians). The presented study compared heart weights between 101 European and 85 Polynesian suicide hanging deaths from New Zealand. Univariate linear regression coefficients for age, male sex, height, body weight, body mass index, and Polynesian ethnicity were positive and significant (P < 0.05). Apart from body mass index, subsequent multivariate analysis showed that all regression coefficients remained positive and significant (P < 0.05). Polynesian ethnicity seemed to be an independent predictor for increased heart weight in the study population. Apart from possible genetic factors, the higher heart weight in Polynesians may have other underlying reasons. Caution is required when interpreting heart weight in cases of sudden natural deaths, especially in this population.

Suicide attempts: epidemiologic trends towards geoprocessing

In order to study data about suicide attempts and do the mapping of occurrence areas, it was developed an ecologic and exploring study, making use of techniques of geoprocessing, based on confirmed cases of suicide attempts. Cases of self-poisoning were included in the urban area of Campina Grande county, in the period of 2010-2013. A total of 446 suicide attempts were geo-referred, pointing up an incidence of 120 cases out of each 100,000 inhabitants. The sample was mostly feminine (66.4%), and 62.3% being up to 30 years old. Kernel's map remarked hot spot areas. Compared to surrounding areas the suicide risk of populations within the hot spots was increased (38%; Relative Risk = 1.38; p= 0.0029), with an average estimative of 165 suicide attempts out of 100,000 inhabitants. Through identification of hot spots and index of living conditions of the neighborhoods, it is possible to set priorities in terms of public policies for the prevention of suicide attempts and control of the marketing of substances that are potentially toxic.

Demographic and Clinical Characteristics of Completed Suicides in Mexico City 2014-2015

Objective: To analyze sex differences in demographic and clinical characteristics of individuals who died by suicide in Mexico City. Method: Statistical analysis of residents of Mexico City whose cause of death was suicide, during two years period from January 2014 to December 2015, with a coroner's report. Suicide mortality rates were calculated by age, sex, and location within the city. The Chi-squared test was used to assess statistical differences. Results: From January 2014 to December 2015, 990 residents of Mexico City died by suicide (men: 78.28%, women: 21.72%). Among males, the highest mortality rates were among the groups of 20-24 and 75-79 years old, whereas in women, the group with the highest mortality rate was 15 to 19 years old. 74% of the sample used hanging as suicide method. However, men had higher rates of a positive result in the toxicology test (40%) (p < 0.05). There was no concordance between male and female suicide by city jurisdictions. Conclusion: Our results provide evidence that the characteristics of Mexico City's residents who committed suicide had significant sex-related differences, including where they used to live. Understanding the contributory factors associated with completed suicide is essential for the development of effective preventive strategies.

Alcohol use by suicide victims in the city of Sao Paulo, Brazil, 2011-2015

Excessive alcohol consumption is a serious public health issue, because drunkenness affects critical judgment and self-control which could trigger violent and self-harm behavior, with thus a potential association between alcohol consumption and suicide deaths. The objective of the present study was to assess the association between alcohol consumption and suicide deaths in the city of Sao Paulo, Brazil, from 2011 to 2015, and its relationship with socio-demographic characteristics of the victims and the circumstances of the suicide. A cross-sectional retrospective study was conducted by collection of data from 1,700 suicide victims subjected to examination of blood alcohol concentration (BAC) from toxicology reports from the Institute of Legal Medicine of the State of Sao Paulo, Brazil. Alcohol was detected in blood samples of 30.2% of the victims and mean BAC levels were 1.73 ± 0.08 g/L. The mean age of the victims was 39.90 ± 0.75 years. The majority of the victims were male (74.6%) and the prevalence of positive BAC was higher amongst men (34.7%) than women (17.1%), p<0.05. The majority of the victims were white skinned (64.7%), but there was a higher proportion of victims with positive BAC among mulatto and black individuals, p<0.05. Hanging was the most prevalent suicide method in the sample (48.7%) and amongst men (55.4%), but amongst women it was jumping from a height (35%), p < 0.05.

Themes and trends in intentional self-poisoning: Perspectives from critical care toxicology

This research investigated the substances employed by and experiences of patients who come to acute treatment after self-poisoning. A retrospective search of the Toxicology Investigators Consortium Registry was performed to characterize a large cohort of patients. A detailed prospective study of one inpatient toxicology service was also conducted. Patients chose readily available agents for self-poisoning. Most cases involved at least one substance that affects the central nervous system (CNS). The majority were prescription psychotropics and narcotics. When they had access to both CNS-active and CNS-inactive medications, patients almost invariably ingested a mind-altering agent. After recovering neurocognitive function, most patients were not actively experiencing suicidal thoughts. However, more than half of patients without CNS toxicity continued to have suicidal ideation after coming to care. These findings are consistent with the hypothesis that many suicidal patients may be seeking an altered psychosomatic state rather than death per se.

Forensic toxicology analysis of self-poisoning suicidal deaths in Tehran, Iran; trends between 2011-2015

Background

Suicide ranks among the top ten causes of death in all age groups all over the world. There are many methods for committing suicide including self-poisoning, firearm and hanging. The aim of the present study was to provide an overview of self-poisoning related suicidal deaths with special focus on forensic toxicology analysis results in Tehran, Iran from 2011 to 2015.

Methods

All suspicious cases with the the history of self-poisoning were investigated to define the cause and manner of death under the supervision of forensic medicine practitioners. Postmortem samples were analysed in forensic toxicology laboratory to confirm the presence of drugs in cadaver of suicidal cases. Drugs and poisons were analysed using thin layer chromatography, high performance liquid chromatography, gas chromatography/mass spectrometry, headspace gas chromatography and gas chromatography equipped with nitrogen phosphorus detector. Demographic data were collected from autopsy reports of all cases with confirmed self-poisoning suicidal cause of death.

Results

Results showed that 674 cases of self-poisoning deaths were investigated during a five-year study period, of which 68.55% were male. The most often used suicide method was self-poisoning in young population. Phosphine gas liberated from aluminum phosphide tablets was the most toxic substance detected in postmortem samples (619 cases) followed by opioids, methamphetamine, organophosphates, cyanide and strychnine.

Conclusion

In conclusion self-poisoning suicidal death was predominant in young male population in Tehran, Iran. It seems that free access to suicide means such as drugs and poisons should be restricted by national and health authorities.

Trial registration

Not applicable.

Increased availability of paracetamol in Sweden and incidence of paracetamol poisoning: using laboratory data to increase validity of a population-based registry study

PURPOSE

To estimate the incidence trend and outcome of paracetamol poisoning, in relation to increased availability of paracetamol from non-pharmacy outlets in 2009.

METHOD

Patients' serum paracetamol results over 14 years (2000-2013) from 20 (out of 21) regions in Sweden were linked to national registers of hospital care, cause of death, and prescriptions. Paracetamol poisonings were defined by serum paracetamol levels, hospital diagnoses, or cause of death. The change in incidence of poisonings following increased availability of paracetamol was analysed by using segmental regression of time series.

RESULTS

Of the 12 068 paracetamol poisonings, 85% were classified as intentional self-harm. Following increased availability from non-pharmacy outlets, there was a 40.5% increase in the incidence of paracetamol poisoning, from 11.5/100 000 in 2009 to 16.2/100 000 in 2013. Regression analyses indicated a change in the trend (p < 0.0001) but not an immediate jump in the incidence (p = 0.5991) following the increased availability. Adjusting for trends in hospital episodes for self-harm, suicides, and the sales volume of paracetamol did not influence the result. All-cause mortality at 30 days (3.2%) did not change over time.

CONCLUSIONS

The incidence of paracetamol poisoning in Sweden has increased since 2009, contrasting the decreased incidence in the period of 2007-2009. The change in trend was temporally associated with the introduction of availability of paracetamol from non-pharmacy outlets but did not appear to be related to sales volume of paracetamol or general trends in self-harm or suicides. © 2017 Commonwealth of Australia. Pharmacoepidemiology and Drug Safety © 2017 John Wiley & Sons, Ltd.

Demographics and post-mortem toxicology findings in deaths among people arrested multiple times for use of illicit drugs and/or impaired driving

BACKGROUND

Multiple arrests for use of illicit drugs and/or impaired driving strongly suggests the existence of a personality disorder and/or a substance abuse problem.

METHODS

This retrospective study (1993-2010) used a national forensic toxicology database (TOXBASE), and we identified 3943 individuals with two or more arrests for use of illicit drugs and/or impaired driving. These individuals had subsequently died from a fatal drug poisoning or some other cause of death, such as trauma.

RESULTS

Of the 3943 repeat offenders 1807 (46%) died from a fatal drug overdose and 2136 (54%) died from other causes (p<0.001). The repeat offenders were predominantly male (90% vs 10%) and mean age of drug poisoning deaths was 5 y younger (mean 35 y) than other causes of death (mean 40 y). Significantly more repeat offenders (46%) died from drug overdose compared with all other forensic autopsies (14%) (p<0.001). Four or more drugs were identified in femoral blood in 44% of deaths from poisoning (drug overdose) compared with 18% of deaths by other causes (p<0.001). The manner of death was considered accidental in 54% of deaths among repeat offenders compared with 28% for other suspicious deaths (p<0.001). The psychoactive substances most commonly identified in autopsy blood from repeat offenders were ethanol, morphine (from heroin), diazepam, amphetamines, cannabis, and various opioids.

CONCLUSIONS

This study shows that people arrested multiple times for use of illicit drugs and/or impaired driving are more likely to die by accidentally overdosing with drugs. Lives might be saved if repeat offenders were sentenced to treatment and rehabilitation for their drug abuse problem instead of conventional penalties for drug-related crimes.

Antecedents and sex/gender differences in youth suicidal behavior

Suicide is the second leading cause of death in youth globally; however, there is uncertainty about how best to intervene. Suicide rates are typically higher in males than females, while the converse is true for suicide attempts. We review this "gender paradox" in youth, and in particular, the age-dependency of these sex/gender differences and the developmental mechanisms that may explain them. Epidemiologic, genetic, neurodevelopmental and psychopathological research have identified suicidal behaviour risks arising from genetic vulnerabilities and sex/gender differences in early adverse environments, neurodevelopment, mental disorder and their complex interconnections. Further, evolving sex-/gender-defined social expectations and norms have been thought to influence suicide risk. In particular, how youth perceive and cope with threats and losses (including conforming to others' or one's own expectations of sex/gender identity) and adapt to pain (through substance use and help-seeking behaviours). Taken together, considering brain plasticity over the lifespan, these proposed antecedents to youth suicide highlight the importance of interventions that alter early environment(s) (e.g., childhood maltreatment) and/or one's ability to adapt to them. Further, such interventions may have more enduring protective effects, for the individual and for future generations, if implemented in youth.