An analysis of age and gender influences on the relative risk for suicide and psychotropic drug self-poisoning

Drug self-poisoning in adolescents: A report of 267 cases

Introduction

The current study aims at describing a sample of adolescents admitted to a tertiary referral pediatric hospital for drug self-poisoning and to identify variables that could explain and predict a higher severity of intoxication.

Methods

We retrospectively reviewed the cases of drug self-poisoning in adolescents admitted to the Bambino Gesù Children's Hospital between January 2014 and June 2022 requiring consultation by the local Pediatric Poison Control Center (PPCC). We reported the type and class of drug ingested and correlated the clinical characteristics of the patients with their Poison Severity Score.

Results

The data of 267 patients were reported. Most patients were female (85.8 %), with a median age of 15.8 years at presentation. Half of the patients were symptomatic at admission (44.2 %), and most had at least one psychiatric comorbidity (71.1 %). Most patients were hospitalized (79.6 %), 16.6 % of cases required antidote administration and a minority required intensive care. Most patients received a PSS score of 0 (59.6 %). The most frequently ingested drug was acetaminophen (28.1 %) followed by ibuprofen (10.1 %) and aripiprazole (10.1 %). Antipsychotics as a class were the most abused drugs (33.1 %). The correlation of clinical variables with the PSS showed that older and male patients were more prone to be severely intoxicated.

Conclusions

This single-center study identifies the most commonly ingested drugs in a large sample of adolescents with voluntary drug self-poisoning, also showing that older and male patients are more susceptible to severe intoxication.

A comprehensive analysis of attempted and fatal suicide cases involving frequently used psychotropic medications

OBJECTIVES

Self-poisoning is the most common suicide method in non-lethal suicide attempts and the third most frequent in fatal suicides. Psychoactive drugs are often used for intentional self-poisoning. While poisons centre data typically focus on survived suicide attempts and underrepresent fatal self-poisoning, medical examiner reports give insight into suicide deaths. To close this gap, we combined and compared data sets from both sources, assessing the mortality of psychotropic drugs used for self-poisoning.

METHODS

Anonymized cases of self-poisoning with suicidal intention from 2000 to 2010 were extracted from the national poisons centre case database and compared with cases of suicide documented in the project "Suicides, a national survey". All cases with single substance exposure to a psychoactive drug (antidepressants, mood stabilizers, antipsychotics, sedatives) were included in the analyses. Opioids, over-the-counter- and illicit- drugs were excluded from the analysis. A mortality index was calculated by the ratio of the number of suicides and the sum of all (lethal and non-lethal) suicide attempts.

RESULTS

Tricyclics had a higher mortality rate than other antidepressants. Among the sedatives, zolpidem was found to have a higher mortality index compared to benzodiazepines. Clozapine and levomepromazine were found to be the most lethal antipsychotics. Non-lethal suicide cases with single substance exposure (n = 4697) diminished as age increased, while the rate of suicide cases (n = 165) was higher in elderly subjects (>65 years of age, p < 0.001).

CONCLUSION

In summary, our findings confirm previous study results on the relative toxicity of distinct classes of psychotropic drugs. In this comprehensive analysis of a national cohort lorazepam had a lower mortality rate compared to other sedatives.

Non-medical use of psychoactive prescription drugs is associated with fatal poisoning

AIMS

The aims of this study were to estimate the prevalence and predictors of non-medical substance use, and to assess the association between non-medical substance use and fatal poisoning or history of drug abuse in Finland.

DESIGN AND SETTING

Retrospective cohort study of all medico-legally investigated death cases in Finland. The postmortem toxicology database was linked together with the register on reimbursed prescription medicines.

PARTICIPANTS AND CASES

All postmortem cases between 2011 and 2013 positive for one or more of the following drugs: oxycodone, fentanyl, tramadol, clonazepam, gabapentin, pregabalin, tizanidine, olanzapine, quetiapine, risperidone, alprazolam, zolpidem, mirtazapine and bupropion, n = 2974.

MEASUREMENTS

Non-medical use of substance was the outcome variable. Predictors were the following: gender, residence at the time of death, place of death, blood alcohol concentration, age, drug abuse, number of prescriptions of any psychoactive drugs in last year and proportion of prescriptions issued by psychiatrist in last year.

FINDINGS

In 50.4% of the studied cases, at least one drug was detected without a prescription. Clonazepam, alprazolam and tramadol were the most prevalent non-medical findings in these cases (6.6, 6.1 and 5.6%, respectively). The risk of non-medical use of prescription drugs was especially high in cases with history of drug abuse (88.5%) and in fatal poisonings (71.0%). The proportion of non-medical use of the studied substances varied between 5.9% [95% confidence interval (CI) = 3.1-10.1%)] for risperidone and 55.7% for fentanyl (95% CI = 44.1-66.9%). Valid prescription for one or more of any psychoactive drug was associated with lower odds for non-medical use of the studied substances. Additionally, the higher the proportion of psychoactive drugs prescribed by a psychiatrist, the lower the probability of non-medical use.

CONCLUSIONS

Non-prescribed psychoactive drugs are found commonly at postmortem in drug poisoning deaths in Finland, with history of drug abuse being a major contributing factor.

Which deliberate self-poisoning patients are most likely to make high-lethality suicide attempts?

BACKGROUND

The risk/rescue rating scale (RRRS) assesses the lethality of a suicide attempt, which is defined as the probability of inflicting irreversible damage. We assessed the lethality of suicide attempts using the RRRS and identified the socio-demographic profiles of patients who achieved high lethality in deliberate self-poisoning (DSP).

METHODS

A retrospective study was conducted to evaluate DSP patients who visited the emergency department of a tertiary teaching hospital between 2000 and 2011. The data included socio-demographic information, clinical variables, risk factors (e.g., the method used, whether consciousness was impaired, toxicity, reversibility and whether treatment was required) and rescue factors (e.g., location, who initiated the rescue, the probability of discovery, the accessibility of rescue, and delay until discovery). The high-risk group consisted of patients with 11-15 risk points, whereas patients in the low-rescue group had 5-11 risk points. We examined the characteristics of high-lethality suicide attempts (high-risk/low-rescue group).

RESULTS

A total of 1114 patients were enrolled in this study. Pearson's correlation analysis showed that the total risk score for patients with DSP was negatively associated with the total rescue score (r = -0.201, p < 0.001). Of the total number of DSP patients, 42 were included in the high-risk/low-rescue group. The multivariate logistic regression analyses showed significant associations between high-lethality suicide attempts and male gender (OR 2.70, 95 % CI 1.41-5.18, p = 0.003), older age (OR 1.02, 95 % CI 1.01-1.04, p = 0.015), and unemployment (OR 2.98, 95 % CI 1.41-6.33, p = 0.004).

CONCLUSION

This retrospective study demonstrates that male gender, advanced age, and unemployed status were associated with high-lethality suicide attempts in DSP patients.

Patterns of toxicity and factors influencing severity in acute adult trimipramine poisoning

AIMS

To analyze the clinical features of trimipramine poisoning, identify a minimal toxic dose, and the dose bearing a 50% risk of developing a moderate, severe or fatal outcome.

METHODS

All acute adult trimipramine monointoxications reported by physicians to the Swiss Toxicological Information Centre between January 1992 and December 2009 were identified.

RESULTS

Two hundred and thirty cases (26 confirmed and 204 probable) were analyzed, the mean age was 35.7 years and 74% were females. One hundred and thirty-seven patients showed mild, 54 moderate and 21 severe symptoms. Three cases were fatal due to refractory cardiovascular collapse. Ninety-three per cent of the events were attempted or completed suicides. The most common symptoms were central nervous system depression (79.2%), tachycardia (19.1%) and QT(c) prolongation (13.9%). The severity of poisoning depended significantly on the ingested dose (P < 0.001). The minimal dose for moderate symptoms was 250 mg (median dose 1.2 g) and 850 mg for severe symptoms (median dose 2.7 g). The dose for a 50% risk of developing a moderate, severe or fatal outcome was 5.11 g. In 38 patients early gastrointestinal decontamination was performed. Overall, these patients ingested higher trimipramine doses than the late- or not-decontaminated patients (P = 0.113). The median doses were also higher in the decontaminated group within each severity category except in the fatal cases.

CONCLUSIONS

We demonstrated that moderate trimipramine poisoning can already occur after ingestion of doses in the high therapeutic range. Poisoned patients have to be monitored for central nervous system depression, dysrhythmias and QT(c) prolongation. Early decontamination might be beneficial.

Drug suicide: a sex-equal cause of death in 16 European countries

Background

There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84).

Methods

Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated.

Results

No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk.

Conclusions

Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Repetition and severity of suicide attempts across the life cycle: a comparison by age group between suicide victims and controls with severe depression

BACKGROUND

Suicide attempts have been shown to be less common in older age groups, with repeated attempts generally being more common in younger age groups and severe attempts in older age groups. Consistently, most studies have shown an increased suicide risk after attempts in older age. However, little is known about the predictive value of age on repeated and severe suicide attempts for accomplished suicide. The aim of the present study was to investigate the reduced incidence for initial, repeated, or severe suicide attempts with age in suicide victims and controls by gender.

METHODS

The records of 100 suicide victims and matched controls with severe depression admitted to the Department of Psychiatry, Lund University Hospital, Sweden between 1956 and 1969, were evaluated and the subjects were monitored up to 2006. The occurrence of suicide attempts (first, repeated, or severe, by age group) was analysed for suicide victims and controls, with gender taken into consideration.

RESULTS

There was a reduced risk for an initial suicide attempt by older age in females (suicide victims and controls) and male controls (but not suicide victims). The risk for repeated suicide attempts appeared to be reduced in the older age groups in female controls as compared to female suicide victims. The risk for severe suicide attempts seemed reduced in the older age groups in female suicide victims. This risk was also reduced in male controls and in male controls compared to male suicide victims.

CONCLUSION

In the older age groups repeated attempts appeared to be predictive for suicide in women and severe attempts predictive in men.

Factors associated with choice of psychotropic drugs used for intentional drug overdose

INTRODUCTION

Knowledge of the factors influencing the choice of drugs used for intentional drug overdose (IDO) may allow the reduction of IDO lethality.

OBJECTIVES

To assess with which frequency subjects with intentional overdose of psychotropic drugs ingest their own psychotropic drug treatment, and whether prescription of a drug may be a factor influencing the choice of drugs used for the IDO.

METHODS

Demographic characteristics, psychiatric history, and currently prescribed psychotropic drug treatment were collected for all the patients (n = 1,654) admitted to an emergency department (ED) for IDO with psychotropic drugs (anxiolytics, hypnotics, antidepressants, neuroleptics and mood stabilizers) over a period of 18 months. Drugs ingested for the IDO were compared in subjects who had ingested at least one psychotropic drug that was prescribed for them and subjects who had ingested psychotropic drugs not prescribed for them using multivariate logistic regression.

RESULTS

Two-thirds of the patients ingested during the IDO at least one of their own prescribed psychotropic drugs. Compared with the subjects who had ingested psychotropic drugs not prescribed for them, they were more likely to have a history of psychiatric hospitalization (OR 4.2; 95%CI 3.1-5.5), of being a psychiatric outpatient (OR 3.9; 95%CI 3.0-5.1), of parasuicide (OR 2.5; 95%CI 1.9-3.3) and a serious IDO (OR 2; 95%CI 1.4-2.9). Independently from age and psychiatric hospitalization history, they ingested during the IDO more often antidepressants (OR 4.4; 95%CI 3.0-6.4), antipsychotics (OR 2.9; 95%CI 1.7-4.8) and mood stabilizers (OR 4.1; 95%CI 1.6-10.7). No association was found with prescription for overdose of hypnotic (OR 1.1; 95%CI 0.8-1.5), anxiolytic (OR 1.2; 95%CI 0.9-1.7) or paracetamol (OR 1.0; 95%CI 0.5-2.1).

CONCLUSION

Prescription of the psychotropic drugs plays an important role in the choice of the drugs ingested for the IDO. It might make potentially "dangerous" drugs available for the patient. Physicians have always to balance the benefit of the treatment against the risk of drug overdose.

Deliberate self-harm in older adults: a review of the literature from 1995 to 2004

BACKGROUND

The prevention of suicide is a national and international policy priority. Old age is an important predictor of completed suicide. Suicide rates in old age differ markedly from country to country but there is a general trend towards increasing rates with increasing age. In 1996 Draper reviewed critically the evidence on attempted suicide in old age in the 10 years between 1985 and 1994. The review highlighted a need for prospective controlled studies in older people with more representative samples as well as studies examining the interaction of risk factors, precipitants, motivations, psychopathology and response to treatment. The aim of this paper is to update this review and to summarise the advances in our understanding of DSH in later life.

METHOD

We have critically reviewed relevant studies published between 1995 and 2004 to summarise the advances in our understanding of factors associated with deliberate self-harm in later life.

RESULTS

The main advances in understanding have been to clarify the effect of personality and cultural factors, service utilisation pre and post attempt, and the (lesser) impact of socio-economic status and physical illness. Methodological weaknesses continue to include inadequate sample sizes performed on highly selected populations, inconsistent age criteria and lack of informant data on studies relating to role of personality.

CONCLUSIONS

Future studies should include prospective, cross-cultural research with adequate sample sizes and which are population-based. Such approaches might confirm or refute the results generated to date and improve knowledge on factors such as the biological correlates of deliberate self-harm, service utilisation, costs and barriers to health care, and the interaction of these factors. Intervention studies to elucidate the impact of modifying these factors and of specific treatment packages are also needed.

Toxicological features of deliberate self-poisonings

BACKGROUND

Deliberate self-poisoning (DSP) is a major health problem with increasing incidence mainly among young people.

OBJECTIVE

To examine the clinical and toxicological characteristics of DSP, it is compared to unintentional (non-DSP) exposures and those characteristics which might be associated with increased toxicological risk are identified.

METHODS

Two-year retrospective poison centre chart review.

STATISTICS

chi2 analysis.

RESULTS

3802 DSP cases were reported. Most calls (95%) were made by physicians compared to 51% in non-DSP exposures, P <0.0001. There were almost twice as many females as males, contrary to unintentional exposures (P <0.001). Peak frequency involvement was at the age of 15-20 years for females and older for males. Only 19.8% of DSP calls were made within the first hour of exposure compared to 46% of the non-DSP calls (P < 0.001). Younger patients tended to present earlier. The vast majority of exposures occurred by ingestion and at home. Pharmaceuticals and chemicals were involved in 86% and 12% of DSP cases, respectively (compared to 29% and 44% in non-DSP exposures, respectively, P < 0.001). Psychiatric drugs were more commonly used in older age groups and analgesics among the younger. Insecticides, sodium hypochlorite and rodenticides were the most frequently used chemicals. Neurological involvement was observed in 48.2% of DSP patients compared to 16.9% in non-DSP exposures. DSP was associated with greater severity than non-DSP exposures (21% and 10% had moderate to severe toxicity, respectively, P <0.001). Severity was greater among males, aged older than 45 years, with time from exposure to consultation 8 hours or longer and with exposure to chemicals, psychiatric drugs or combinations.

CONCLUSIONS

Most DSP patients were females, aged 15-20 years, used pharmaceuticals and had neurological involvement. Males, aged over 45 years, with longer time to toxicology consult and the use of chemicals were associated with increased severity. These parameters should alert the treating physician to the possibility of a poor course and hence to a more aggressive therapeutic approach.

Data collection in clinical toxicology: are there too many variables?

The evidence base of clinical toxicology suffers in comparison to other clinical disciplines. There is an excess of case reports and case series with little in the way of case control or cohort studies, and very few randomized controlled trials. While randomized controlled trials are rightly regarded as the gold standard for interventional studies, they have limitations that are particularly evident in the practice of clinical toxicology. Properly conducted observational studies using quantitative, epidemiological methods [nonrandomized trials, cohort studies (prospective and retrospective), case control methods] can provide answers that may be impossible to obtain from randomized controlled trials. Development of a strong evidence base is essential for progress in clinical toxicology. Whether that evidence base is derived from randomized controlled trials or observational studies, it is essential to collect data. Important observations can be made from basic clinical data and systematic collection of those data into some form of electronic database has siginificant advantages. A clinical database provides accurate information in the areas of clinical practice, quality assurance (audit), and research. In the area of research, an appropriately designed database can be both a source of hypotheses as well as a vehicle to test them. It can also serve as a repository of research data in subsequent randomized controlled trials.

Poisoning and epidemiology: 'toxicoepidemiology'

1. There is little hypothesis-testing clinical research performed in toxicology. Randomized clinical trials are rare and most observational studies are performed on highly selected patients and are subject to marked bias. Thus, for many poisonings, our approach has been based almost entirely on deduction from known pharmacological/toxicological effects, generalizations from drugs within the same therapeutic class, animal data and case reports. This is also far from satisfactory, as many toxicological mechanisms are poorly understood and not related to the therapeutic class. 2. Although we need much better data to address the clinical and public health aspects of poisoning, there are many practical and ethical reasons why randomized clinical trials are difficult in this field. However, the scope for observational research, in particular population-based clinical epidemiology, is almost unlimited. The collection of data on human poisoning is facilitated because most non-fatal overdoses are admitted to hospital and by legal requirements to report to the coroner deaths that are due to poisoning. In the present article I argue that 'toxicoepidemiology', meaning the application of epidemiological methods to the problem of acute poisoning, is the best means we have of addressing deficiencies in our knowledge of poisoning. 3. Examples are given of a variety of observational research strategies, ranging from audit to meta-analysis, that may be applied to clinical toxicology. From coronial and clinical data obtained from reasonably well-defined populations, it has been possible to identify a number of previously unrecognized differences in the severity and spectrum of toxicity between and within drug classes. Also, the demographic risk factors for poisoning and the reproducibility, validity and optimal use of diagnostic and therapeutic interventions can be assessed. 4. The major limitations to the range of associations and interventions that may be studied are the need to achieve adequate power to study uncommon outcomes or poisonings and the ability to replicate findings at other centres using similar methodology. The expansion of data collection to other centres has the potential largely to overcome these obstacles.