Lethal Intoxication Research Articles

Toxicological hazards of natural environments: Clinical reports from Poison Control Centre of Milan

The belief that approaching nature can enhance well-being, widely promoted by mass media, is widespread. People explore parks and forests searching for wild herbs, berries and mushrooms that could be used as food or medicines, thinking that all things natural are healthy and harmless while picking up toxic species or encountering a snake is not so infrequent. To point out the Italian cases concerning these natural poisons, all cases handled between 2001 and 2005 by Poison Control Centre of Milan, the leading toxicological centre in Italy, have been reviewed. Regarding plants, 4432 records were collected; the patients most frequently involved were children that had picked poisonous species at home, at school or in other public places, but the most serious cases were related to wild plants used by adults for health enhancement: three deaths were recorded. Among 4289 calls concerning mushrooms several life-threatening cases, 6 transplants and 9 deaths were recorded. Eventually, 2072 records connected to snake bites were collected, among them at least 1061 were related to Vipera spp.: three patients died. These accidents can lead to severe or lethal poisonings that, requiring intensive medical cares and antidotes, have also a social and economic cost to the National Health Service. A public information campaign should be promoted to make people more aware of the risks of these events and of the detrimental consequences that this could have. Some cases of poisonings have arisen due to incorrect information conveyed through radio, television, press and the Internet; we highlight the need for better control on the content of messages diffused through mass media.

Life‐threatening hypokalaemia and lactate accumulation after autointoxication with Stacker 2®, a ‘powerful slimming agent’

In recent years the use of so-called fatburners such as Stacker® has gained widespread popularity in the USA. These dietary supplements contain substances such as Ephedra and caffeine.The drugs are supposed to stimulate athletic performance and reduce body weight [1]. Ephedra, also known as the Chinese ‘Ma Huang’, is a plant-derived natural source of the sympathicomimetic substance ephedrine. Caffeine (1,3,7-methylxanthine) is also a plantderived stimulant alkaloid, which can be obtained from tea leaves, coffee beans, cacao beans and cola nuts. Its pharmacological actions are diverse, but finally result in an increasing release of endogenous catecholamines and therefore augment the effect of Ephedra alkaloids. For years, Ephedra-containing food supplements were easily available over-the-counter herbal products in the USA and the Netherlands. When serious adverse events including stroke, heart attacks, cardiac arrhythmias, seizures and psychotic disorders were reported, the general sale of Ephedra-containing products was prohibited. However, Ephedra alkaloids can still easily be obtained through the internet or at gyms. Furthermore, an increase in the use of Ephedra-free fatburners, which are considered as ‘safe’ products, has been observed. In the following case report we describe a remarkable, potential lethal intoxication with Stacker 2®. A 22-year-old woman with no previous medical history was admitted to our emergency room because of attempted suicide. She claimed to have ingested approximately 50 tablets of Stacker 2® ephedra, which had previously been provided by her gym. According to the label on the bottle, its main constituents were Ephedra, cola nuts and white willow bark (NVE Pharmaceuticals®, Andover, NJ, USA).The patient reported not having taken any alcohol or other medication. Furthermore, she had not been exercising on the day of admission. On arrival, she complained of thirst, headache, abdominal pain, chest pain and she vomited several times. On examination, an anxious, hyperventilating and extremely agitated woman was observed with clammy peripheries. Vital signs included a temperature of 37.5 °C, blood pressure of 122/66 mmHg, a regular pulse of 110 bpm and a respiratory rate of 25/min. Her arterial saturation was measured at 99%. Pupils were bilaterally dilated and responsive. Apart from modest abdominal tenderness, physical examination revealed no other abnormalities. Laboratory results are shown in Table 1. Because of the strikingly low serum potassium concentration (1.6 mmol l-1), laboratory measurements were verified several times. Also remarkable was the elevated serum lactate (7.2 mmol l-1). Electrocardiography demonstrated sinustachycardia with ST-depression and U-waves in precordial leads V1–V3. Potassium chloride at a rate of 20 mmol h-1 was administered. Furthermore, sodium-potassium-phosphate was supplemented.The patient was transferred to the Intensive Care Unit for haemodynamic monitoring. Polyuria was observed with a diuresis of 250 ml h-1. The following day, the patient was less agitated, but still complained of nausea, vomiting and abdominal pain. Her respiratory rate still measured 22/min. Tachycardia had disappeared. The serum potassium concentration had increased from 1.6 to 3.8 mmol l-1. Serum lactate had decreased to 3.5 mmol l-1 (Table 1). The patient was transferred to the ward and discharged home 7 days after admittance. Subsequently, toxicological analysis for caffeine was performed by means of high-pressure liquid chromatography UV detection: platinum enhanced polar selectivity C18 column, particles; 3 mm, size 10 ¥ 4.6 cm; Alltech®, photodiode array detector (Waters®, Milford, MA, USA). The mobile phase consisted of a solution of water, phosphor acid, nonilamine (67%) and acetonitril (33%). Ephedrine British Journal of Clinical Pharmacology DOI:10.1111/j.1365-2125.2008.03279.x

Central roles for IL-2 and MCP-1 following intranasal exposure to SEB: A new mouse model

Murine models for bacterial superantigens like staphylococcal enterotoxin B (SEB) have to date been rather cumbersome. The reasons include: (1) necessary use of potentiating agents such as actinomycin D, d-galactosamine, lipopolysaccharide (LPS), or viruses; (2) high toxin amounts required to elicit effects; and/or (3) generation of phenotypic-stable transgenic animals. Our study employed readily available C3H/HeJ (TLR4 negative, LPS-nonresponsive) mice with intranasal and intraperitoneal administration of low microgram quantities of SEB. These animals responded to SEB with severe lung inflammation and hypothermia, culminating in death. A survey of cytokines/chemokines in sera and lungs after lethal intoxication revealed that monocyte chemoattractant protein-1 and interleukin-2 were associated with effects in this model. In contrast, SEB had minimal effects upon congenic (TLR4 positive, LPS-responsive) C3H/OuJ mice. Lethality of SEB in C3H/HeJ mice was neutralized with SEB-specific antibodies, suggesting potential utility of this model for future therapeutic studies.

ARSENOLIPIDS IN FISH OIL

ARSENIC, A HAZARDOUS heavy metal, associates with lipids in fish, researchers have found ( Chem. Commun. , DOI: 10.1039/b808049f). The discovery of arsenic in oil from capelin ( Mallotus villosus ), a North Atlantic fish in the smelt family, and the prospect that it could also be present in other fatty fish, could have important implications for human health and the ocean environment. Arsenic is a lethal poison and thus a major environmental and health hazard. Most human exposure to the metal occurs through water, and the majority of research on arsenic toxicity has focused on this. Scientists had previously believed that any arsenic found in fish would be water-soluble; they were surprised to find it in lipids. This discovery of arsenic in fish oil adds to health concerns, especially because many dietitians encourage people to increase their fish consumption. A group led by Kevin A. Francesconi, professor of chemistry at the University of Graz, in Austria, has now ...

Acute Aluminium Phosphide Poisoning: An Update

Acute aluminium phosphide poisoning is an extremely lethal poisoning. Ingestion is usually suicidal in intent, uncommonly accidental and rarely homicidal. Unfortunately the absence of a specific antidote results in very high mortality and the key to treatment lies in rapid decontamination and institution of resuscitative measures. This article aims to identify the salient features and mechanism of aluminium phosphide poisoning along with its management strategies and prognostic variables.

Lethality from acute intoxications with organophosphate pesticides in Varna region for a period of 15 years

An analysis of the lethality in cases of acute exogenous intoxications (AEI) with organophosphate pesticides (OP) in Varna region for a period of 15 years -1991-2005 was done. It was established that from 207 patients with acute OP poisonings there were 40 lethal cases. The frequency of the lethal cases was 19.32%. 28 (70%) of them were men and 12 (30%) were women. The lethality was significantly higher in men. The proportion of lethal cases in men and women was 2.33: 1. The average age of deceased patients was 59 years. It was reported that with growing up of the age the average lethality had grown bigger too. All the lethal poisonings were by an oral ingestion. In 35 cases (87.5%) suicidal attempts were done and in 5 cases (12.5%) accidental household poisonings took place. The main reason about the death was a development of syndrome of multiorgan insufficiency (SMOI). Scripta Scientifica Medica 2008;40(1):31-33

Metamizol - akute Überdosierung in suizidaler Absicht

An 18-year-old girl swallowed 98 tablets of Novalgin (corresponding to 49 g metamizole) with suicidal intent. After stomach lavage she received forced diuresis for 14 hours. Metamizole metabolites in serum and urine were measured by thin-layer chromatography. After 24 hours the serum concentration of metamizole metabolites was still clearly elevated. Renal elimination amounted to 11 g metamizole. The patient survived the severe overdosage without significant organ abnormalities. This favourable course differs from reports of lethal intoxication with other pyrazolone derivatives, especially those with metamizole combination drugs. The forced diuresis proved to be a satisfactory elimination procedure. Biotransformation and elimination of the metamizole metabolites still continued after 24 hours.

A Comparison of Methadone, Oxycodone, and Hydrocodone Related Deaths in Northeast Ohio

Increases in methadone and oxycodone related deaths have been recently documented in the United States. In response to these reports, the authors investigated cases over a six-year period in which postmortem toxicological analyses revealed the presence of methadone, hydrocodone, and oxycodone. The study was designed to determine whether regional methadone-associated mortality in Cuyahoga County reflected national trends and more specifically, to distinguish methadone mortality from other commonly used opioid analgesics. All records of decedents that were found to be positive for methadone, hydrocodone, and/or oxycodone in 1998-2003 were reviewed. The cause and manner of death and demographic information was compiled. The cases were divided into lethal intoxications and cases where a positive result was determined to be an incidental finding. Lethal intoxications as a result of only methadone, hydrocodone, or oxycodone were separated from polydrug intoxications. Thoroughout the study, an increase was observed in the number of positive cases. In contrast to recent national data, although the number of methadone-positive cases increased from 4 in 1998 to 18 in 2003, this did not result in an increase in methadone overdoses [1 death in 1998 (25%) to 4 deaths in 2003 (22%)]. Although the pharmacokinetic profiles differ, methadone, hydrocodone, and oxycodone lethal intoxications equally comprised 28-29% of cases in which these drugs were detected. There was an overlap in the range of blood concentrations observed for the drug-related death groups and the incidental finding groups. However, mean and median concentrations in oxycodone and hydrocodone related deaths were more than two times greater than those in non-drug-related deaths.

The management of severe toxic alcohol ingestions at a tertiary care center after the introduction of fomepizole

Introduction Ethylene glycol and methanol ingestions are relatively uncommon but potentially lethal poisonings. Recent trials have demonstrated that fomepizole effectively blocks alcohol dehydrogenase (ADH) in toxic alcohol overdoes, and may eliminate the need for emergent hemodialysis and intensive care unit admission. However, controversy remains in the role of fomepizole in clinical practice. The purpose of this study was to describe the presentation, management and clinical course of toxic alcohol ingestions at a tertiary care referral center after the introduction of fomepizole to hospital formulary. Methods Data was collected on all patents treated for toxic alcohol ingestions for a 1-year period in a tertiary care referral center. Patients who received fomepizole or ethanol infusions, or who underwent hemodialysis were indentified by ED, pharmacy, hemodialysis and ICU databases. The patients' medical records were reviewed, and data was recorded on a predetermined computerized data collection form. Results Overall, twenty (20) toxic ingestions (14 methanol; 6 ethylene glycol) were identified over the one year period. Fomepizole was used for ADH blockade in 12/20 cases; ETOH infusions in 15/20 cases (combined ETOH and fomepizole use in 7/20). The majority of toxic alcohol exposures were admitted to an intensive care unit (19/20) and received emergent hemodialysis (19/20). All patients were discharged from hospital alive. Conclusions Patients with methanol and ethylene glycol ingestions who presented to our centers had significant toxicity and received both HD and ICU admission. Further research is required to determined if the method of ADH blockade affects the need for hemodialysis or ICU admission in toxic alcohol ingestions.

Toxicological Investigation of Drug-Related Cases in Greece: Interpretation of Analytical Findings

The process of toxicological analysis of postmortem specimens can reveal some special difficulty compared to the clinically derived specimens. Many drugs are not stable and the chemical changes that occur in the specimens, due to the hydrolysis processing, the time passed, the drug metabolism, and matrix effect, even when the postmortem interval is short, may affect the interpretation of the toxicological results. This interpretation may be critical, not only to the thorough investigation of different kind of forensic cases, but also to clinical or other cases as it provides very significant challenges to the scientists. This article reviews (a) particular toxicological issues associated with some toxic substances responsible for common lethal or nonlethal poisonings, such as opiates, cannabis, and cocaine and the vast number of factors that affect drug concentration; and (b) focuses on toxicological issues associated with the analytical findings of certain postmortem specimens. The toxic substances cited in the present paper are the most commonly found in forensic cases in Greece. The investigation of these drug-related deaths has revealed that heroin, alone or in combination with other psychoactive substances, such as cannabis and cocaine, is the main drug involved in these deaths.

Dry Fruit Bezoar Causing Acute Small Intestinal Obstruction

story is told that a castle in Cordova, Spain, was given in exchange for a bezoar. In A Voyage to Abyssinia, written by Father Jeronimo Lobo in the 17th century, based on his travels to Boa, he says: “I had recourse to bezoar, a sovereign remedy against these poisons, which I always carried about me.” Belief in bezoars’ near-magical properties was then common. The magical medical properties of bezoars were tested in 1575 by the French surgeon Ambroise Pare. A cook at Pare’s court was caught stealing fine silver cutlery, and Pare offered the thief a choice between public strangulation and swallowing lethal poison along with a bezoar stone. The cook agreed to be poisoned and then treated with a bezoar stone, but to no great avail as he died in agony days later. It difficult to imagine the high esteem of bezoars in those days if one thinks of the foul-smelling masses On December 26, 2005, a 56-year-old woman presented to the ABC Medical Center in Mexico City complaining of abdominal pain. She had no teeth and had practically swallowed dry fruit whole during Christmas dinner. On presentation, she had abdominal distention and pain. An abdominal radiograph revealed a bowel mass in the right iliac fossa. An exploratory laparotomy revealed numerous undigested fragments of dry fruit causing luminal obstruction of the terminal ileum (Figure 1). Acute intraluminal occlusion of the small bowel is uncommon. Among the causes, bezoars are the most common, usually occurring in patients with a history of previous gastric surgery, poor mastication, overindulgence of food with a high fiber content, or psychiatric ailments. A bezoar is a large mass of undigested foreign material usually made of hair (trichobezoar), vegetable material (phytobezoar), or persimmon pulp (diospyrobezoar) that collects in the gastrointestinal tract. Bezoars composed of concentrated milk products (lactobezoar) and of mixed medication and food bolus have also been described. Bezoars were believed to have the power of universal cure against any poison. The word bezoar means “antidote” and comes from the Persian pâdzahr or the Arabic bedsehr. In fact, some types of trichobezoar are apparently able to participate in the binding of arsenic compounds from solutions. Bezoars could be swallowed or rubbed on the infected part and became prized possessions. The

Fatal Mephenesin Intoxication

This report describes a death related to the abuse of and intoxication by mephenesin. To the best of our knowledge, this is the first report case of lethal intoxication involving solely mephenesin and reporting mephenesin blood concentrations. The victim was a 48-year-old woman found unconscious at home. Resuscitation was unsuccessful. Toxicological analysis was performed on a blood sample collected during resuscitation. The results being negative, the body was exhumed for an autopsy, which revealed bronchial inhalation syndrome. Analysis in a second laboratory has revealed the presence of mephenesin in samples collected during autopsy. No other drug/toxin was found, and alcohol was negative. Reanalysis of the peripheral blood collected during resuscitation found a mephenesin concentration of 15.81 microg/mL (15-fold greater that the maximum concentration that would result from a single intake of a 500 mg formulation). The pathologist has concluded on a bronchial inhalation syndrome consecutive to a mephenesin overdose as the cause of death. The manner of this death is discussed in the light of the toxicological hair analysis and the medical past of the victim.

Acute cerebral white matter damage in lethal salicylate intoxication

A 34-year-old oligophrenic woman was admitted in comatose state with marked tachypnea. History revealed the oral ingestion of a large amount of acetylsalicylate to attenuate ear pain within the preceding 3 days. Laboratory investigations showed a toxic concentration of serum salicylate (668 mg/l, toxic range above 200 mg/l) and metabolic acidosis. Oxygenation, blood pressure, electrocardiography, echocardiography and CT of thorax and brain were normal. The patient was intubated, fluid and bicarbonate was given intravenously. Six hours after admission asystolia refractory to resuscitation led to death. Autopsy showed venous congestion of the brain, cardiac dilatation and pulmonary edema. Brain histopathology showed myelin disintegration and caspase-3 activation in glial cells, whereas, grey matter changes were sparse. Acute white matter damage is suggested to be the substrate of cerebral dysfunction in salicylate intoxication and possible mechanisms are discussed.

Fatal Amphetamine-Associated Cardiotoxicity and Its Medicolegal Implications

Amphetamines are popular drugs of abuse, particularly among youngsters and at dance scenes. Cardiotoxicity (manifested as cardiomyopathy, acute myocardial infarction/necrosis, heart failure, or arrhythmia) after the recreational (mis)use of amphetamine and its synthetic derivatives has been documented but is rather rare. Amphetamine-related cardiac fatalities are even more rare. We present 6 cases of young persons who died unexpected after the chronic abuse of amphetamines. Death was not attributed to a lethal intoxication but to an acute myocardial necrosis, a right ventricle rupture, a cardiomyopathy, or an arrhythmia. Two of the deceased persons presented prior to their death to the emergency department, but their complaints were not considered (probably due to their young age) to be of cardiac origin. One case was a sport-related fatality where medical screening failed to identify the underlying cardiac pathology or the amphetamine abuse, and 1 case was a so-called idiopathic dilated cardiomyopathy where substance abuse was not considered by the treating physician. We think that amphetamine-associated cardiotoxicity is a rare but probably genuine entity that should be considered both in forensic and clinical/emergency medicine because of its potential medicolegal implications.

Engineering Enemy-free Space: An Invasive Pest that Kills its Predators

The biological invasion of the glassy-winged sharpshooter, Homalodisca coagulata, into French Polynesia presents a novel threat to Pacific Island ecosystems. Widely known as an agricultural pest because of its role as a vector of numerous lethal plant diseases, H. coagulata may pose a substantial and immediate risk to arthropod predators on invaded islands in French Polynesia. Controlled feeding experiments revealed that island spiders can be killed following predation on H. coagulata. Spider mortality appeared to result from lethal intoxication, although no form of chemical defense has been reported in H. coagulata. In the two spider species tested, approximately half of all individuals that attacked H. coagulata nymphs or adults died. As populations of this insect increase in size and range on invaded islands in French Polynesia, H. coagulata will increasingly encounter these and other arthropod predators, raising the possibility of population-level impacts on susceptible predator species. Field surveys of island spiders across nine sites on H. coagulata-invaded and H. coagulata-uninvaded islands suggest that this insect may already have adversely impacted an endemic spider on at least one island. Work is needed to identify the nature of the lethal agent harbored within H. coagulata and the taxonomic and geographic breadth of predators vulnerable to it. The generality of H. coagulata-lethality and the capacity of afflicted predator species for population-level adaptation or learned avoidance in response to this spreading pest will determine the magnitude of the threat H. coagulata poses in the South Pacific.

Cause and Motivation in Cases of Non-Fatal Drug Overdoses in Opiate Addicts

Introduction. Drug overdose (OD) is a frequent incident among opiate addicts. Survivors of ODs are at risk for additional and eventually fatal ODs. ODs may be classified as accidental (aOD) or deliberate (dOD). Investigations into the connection between OD and suicide attempts have led to insconsistent results. Purpose. () to determine how many non-fatal ODs were dODs and how many were aODs; () to determine how many cases of dODs were motivated by explicit or by ambivalent suicidal intentions; () to determine how many cases of aODs had causes that might respond to preventative measures; () to compare the addiction histories of dODs and aODs; () to compare the drugs causing the ODs; and () to compare the severity of the ODs in both groups. Methods. Prospective study utilizing a standardized questionnaire to evaluate opiate-addicted patients admitted to our treatment unit for OD. All cases underwent standardized drug testing to identify drug use patterns. Results. Seventy-four cases of OD underwent standardized interviews after awakening. Forty-three percent of the cases were dOD. Cases of dOD had significantly more OA in substitution programs, more previous ODs, and more often consumed methadone and cocaine. Among dODs, 22.5% had suicidal intention and 9.6% were ambivalent about committing suicide; background motivations were most often conflicts with spouses. Fifty-seven percent of the cases were aOD. Cases of aODs had significantly more potential lethal intoxications and had heroin detected more frequently. aODs happened with unexpected pure heroin (46%), in combination with alcohol (36%), as relapse after abstinence (40%) or after institutionalized treatment (19%). This group should be accessible for targeted education.

Detection of colchicine by means of LC-MS/MS after mistaking meadow saffron for bear's garlic.

The accidental ingestion of plant material containing colchicines is a rare cause of lethal poisoning. The death of a married couple who mistook colchicines for Bear's garlic (Allium ursinum) and prepared the latter as a salad is the tragic topic of this article. After discussing the specificity of the histological findings, a chemicotoxicological method using liquid chromatographic mass spectrometric (LC-MS/MS) is presented. Toxicological analyses using LC-MS/MS revealed colchicine concentrations between 36.6 ng/mL and 98.3 ng/mL in the heart blood and between 22.7 ng/mL and 78.4 ng/mL in the femoral blood of the victims.

Toxic Alcohol but not Intoxicated-A Case Report

Ethylene glycol is recognised as a potentially lethal poison if ingested. Approximately 100 mls may be fatal in a 70 kg adult. Current Toxbase guidelines are the accepted standard of treatment of such poisonings in the United Kingdom. These guidelines suggest that symptoms of significant poisoning are usually present within 30 minutes of ingestion i.e. ataxia, dysarthria, nystagmus, nausea and vomiting, haematemesis, coma and convulsions. In the absence of these symptoms, metabolic acidosis or ethylene glycol concentration more than 8 mmol/l a single loading dose of ethanol and observation were the recommended course of management until recently. We report a case of a patient who remained relatively asymptomatic for almost 24 hours but then developed clinical symptoms with marked metabolic acidosis and renal impairment requiring intensive treatment including haemodialysis.

Lethal intoxication with hydrofluoric acid

Intoxication with hydrofluoric acid is a very rare but mostly lethal clinical condition. It is mainly caused by dermal exposure, with ingestion extremely rare. Hydrofluoric acid is one of the strongest acids known that has a strong lipophilic ability. Ingestions of more than 20 mg/kg body weight are considered a lethal dose. Even after dermal exposure, the fatal prognosis is caused by severe electrolyte disturbances, especially hypocalcemia. We report on a 50-year-old female with endogenous depression who swallowed approximately 30 ml hexafluorosilicate (hydrofluoric acid) during a night-time attempt to commit suicide. In the early morning, the woman was found somnolent in a condition of circulatory shock. She complained of severe abdominal pain. She had to be intubated by the emergency doctor and was admitted to the hospital. Physical examination of the mechanically ventilated patient only revealed conjunctival irritation. Laboratory investigations showed severe electrolyte disturbances (hypokalemia, hypocalcemia, hypophosphatemia decreased magnesium levels) as well as severe metabolic acidosis. Within the next few hours, disseminated intravascular coagulation and hyopalbuminemia developed. Serum fluoride levels were 0.099 mmol/l or 1.98 mg/l (normal values 0.0005–0.02 mmol/l or 0.1–0.4 mg/l). Urine fluoride levels were 1.94 mg/l (normal values <1.0 mg/l). Gastroscopy showed necrotic gastric mucosa without signs of bleeding. Topical instillation of calcium was not performed due to the long time interval from burn to treatment but intravenous calciumgluconate was substituted immediately. Despite fluid resuscitation, correction of the electrolyte abnormalities, stabilisation of coagulation and substitution of albumin, the clinical condition worsened. The patient had to be defibrillated due to ventricular fibrillation about 30 times. Later on, these episodes of ventricular fibrillation were becoming less responsive to defibrillation although the electrolyte threshold had already been corrected. After 12 hours, the patient died under cardiopulmonary resuscitation. On autopsy, severe burns were found in the esophageal and gastric mucosa, hyperemic lesions were seen in the renal tubular system as well as necrotic lesions in the cardiac musculature. Besides the poor prognosis of a fluoride intoxication in this dosis, the long time interval until treatment could be started seems to be the main reason for the fatal outcome of this case.

Suicide in severe depression related to treatment

The objective of the present study was to assess the association between depressive characteristics and completed suicide despite adequate antidepressant therapy in severe depression and to investigate the frequency of lethal antidepressant overdoses. A record evaluation of 98 suicide victims with a primary severe depression had been performed. These had been admitted to the Department of Psychiatry, Lund University Hospital between 1956 and 1969 and followed up to 1998. Psychomotor retardation was related to completed suicide after ECT. The estimated frequency of lethal intoxication with antidepressants was low: 3% of the suicides.