Poisoning suicide due to paroxetine overdose toxicity aided by benzodiazepine and antipsychotic drugs

This contribution presents a case of suicide death due to ingestion of paroxetine in overdose by a 22-year-old psychiatric patient. The deceased was found dead in his room with blood exiting his nose and dry bloodstains on his left wrist. Many empty and semi-empty packets of prescribed medications were found in the scene. On internal examination, the urinary bladder was markedly distended, and the organs showed autolytic changes with no other macroscopic pathological lesions. Blood (from the left external iliac vein), urine, and gastric contents were sampled for toxicological analysis. The toxicological screening revealed the presence of the antidepressant selective serotonin reuptake inhibitor (SSRI) paroxetine, the benzodiazepine alprazolam and its metabolite alpha-hydroxy-alprazolam, and the antipsychotic quetiapine in blood, urine, and gastric contents, and the presence of nor-clozapine in urine. Quantitative analysis showed lethal blood paroxetine concentration of 3.3 mg/L and 1.58 mg/L in urine. Based on the medicolegal autopsy, the medical history, the circumstances of death by the police, the toxicological results and the pharmacology of the involved drugs, the manner and cause of death were recorded as suicide and, mixed-drug intoxication due to the synergistic action of the primary toxicant paroxetine and the secondary contribution of alprazolam, quetiapine and clozapine, respectively. It was classified as X61 in International Classification of Diseases (10th revision). This is the first fatal case reporting the simultaneous presence of antipsychotics (quetiapine and clozapine) and benzodiazepines (alprazolam) with toxic paroxetine levels.