Post-aggression suicide under the influence of new psychoactive substances AMB–FUBINACA and U-47700

The objective of the present study was the development and validation of the method for determining AMB-FUBINACA and its metabolite - AMB-FUBINACA O-desmethyl acid – in blood samples, followed by verification of the method in toxicological judicial and forensic medicine practice employing the example of post-aggression suicide. Most likely in consequence of development of adverse effects resulting in psychotic symptoms, a male being under the influence of the synthetic cannabinoid AMB-FUBINACA and the new synthetic opioid U-47700, mortally wounded his female partner and subsequently committed suicide. Identification and determination of the afore-mentioned xenobiotics in blood samples collected from the male and female victims were performed employing high performance liquid chromatography coupled with electrospray ionization tandem mass spectrometry (HPLC-ESI-MS/MS). The analytes were isolated from blood samples using the solid phase extraction (SPE) method. The blood samples collected from the male and female demonstrated respectively 110 and 196 ng/mL of AMB-FUBINACA O-desmethyl acid metabolite, 1935 and 357 ng/mL of U-47700, 250 and 200 ng/mL of N-desmethyl-U-47700, as well as 410 and 200 ng/mL of N,N-didesmethyl-U-47700. The concentration values of new psychoactive substances (NPS’s) in blood samples originating from the male and female were within the ranges encountered in cases of poisoning, including these resulting in death. Nevertheless, the evident signs of exsanguination proof that the woman was alive when she sustained lethal injuries. The presented cases illustrate the difficult to be anticipated effect exerted on the users by NPS’s.     

Ten years psychosocial outcomes among adolescents following suicide attempts – early recurrence and psychosocial outcomes

ObjectivesA suicide attempt (SA) is a major risk factor of recurrent SA in adolescence and may be associated with psychological or social problems in the future. REPEATERS is a longitudinal study which examines the long-term psychosocial outcome of adolescents following attempted suicide. It focuses on the impact of early recurrence (i.e., within the first year of the index SA) – data which is, in fact, poorly documented.MethodsTen years after the index SA, a self-reporting questionnaire was sent to all adolescents who had attempted suicide and were followed up by the CHRU (Regional University Hospital Centre) de Nancy, France, between 1994 and 2003 and their parents. The purpose of this questionnaire was to assess psychosocial outcomes. Data concerning SA were collected retrospectively.ResultsAfter ten years, 146 of the 309 adolescents who had attempted suicide and were participating in the study had responded: 90% lived with a partner and 41% had children. The mean (SD) current emotional life of suicide attempt survivors scored 7.3 (2.3) on a scale of 0 to 10. Compared to the general population of the same age, responders felt more depressed than their peers (29% vs. less than 8% of males and 20% of females), had more suicidal thoughts (14% vs. 5%), and had more SAs (27% vs. 0.3%). Moreover, the risk of recurrence over the ten year period was associated with suicide recurrence in the first year after the index SA (odds ratio [OR] = 2.3; 95% confidence interval [CI] = 1.1–4.9) and with a lower level of education at ten years (OR = 0.37; 95% CI = 0.19–0.45).ConclusionsAlthough a favorable outcome was reported ten years after the event for the majority of adolescents who had attempted suicide, some with a lower level of education were nevertheless at increased risk of recurrence and depression. Post-intervention strategies are therefore essential in order to evaluate risk factors which may persist if not taken into consideration.     

Droit à mourir et suicide assisté : état des lieux et analyse critique

ObjectivesIn the context of the present re-examination of the French bioethical laws by the National Advisory Ethics Committee (“Comité consultatif national d’éthique”: CCNE), a recent survey indicated a request of the public opinion to obtain a medical aid in end of life and a so-called “assisted suicide”. This led psychiatrists to re-consider their role and deontological position which usually led them to consider a request for an assistance in suicide as – a priori – a pathological demand, occurring within a suicidal crisis. The present article intends to: 1) describe the laws and practices of countries which allow medically assisted end of life help procedures; 2) clarify the definitions of “assisted suicide”, “assistance to suicide” and “euthanasia”; 3) consider available epidemiological data and the roles given to doctors and, more specifically psychiatrists, in these procedures; 4) analyse the rationale behind these demands. These considerations should enable French psychiatrists to clarify their position when facing requests for a medical aid in dying.MethodsFour European countries (Switzerland, the Netherlands, Belgium, Luxemburg) and Oregon (the first US state to introduce legislation) were considered, since they accumulated and published a large amount of experiences and data about “assisted suicide” and medical help in dying. In total, 127 articles were selected, mainly from PubMed and Cairn databases, published between 1997 and 2020. These articles deal with legal considerations, epidemiological data, ethical and sociological considerations.ResultsLaws and practices differ notably according to the state/country. In Belgium, the Netherlands and Luxemburg, as in Oregon, the medical help in dying has been de-criminalized, as long as certain legal criteria are met. In Switzerland, where no specific law exists in the penal code, non-governmental associations have benefited from the legal vacuum and organized the practice of “assisted suicide” for “altruistic motives”. In the scientific and legal literature, the terms used to describe and define the medical help in dying upon request differ greatly. In France, the National Advisory Ethics Committee defines euthanasia (“euthanasie”), assisted suicide (“suicide assisté”) and suicide assistance (“assistance au suicide”). Available epidemiological data, whatever the country considered, indicate that requests for a medical aid in dying are expressed mainly by patients aged over 60 years and suffering from cancer. Psychiatric diseases account for only 1% to 3%. Most often, systematic assessment by a psychiatrist is neither requested nor made, when the demand does not occur during a primary psychiatric illness. In the case of an existing primary psychiatric pathology, a psychiatrist assesses the case against formal legal predefined criteria. This latter practice was only recently introduced, after some feedback and after legal actions had been brought to Court. When the underlying motivations of the request are considered, it appears that, even in the absence of an evolving psychiatric condition, several psychological or psychopathological reasons prevail such as spirituality, attachment style, social isolation, despair, depression… which should greatly benefit psychiatric exploration, investigation and expertise.ConclusionIn some countries, the request for medically assisted help in dying has become a legal and social reality. In France, where the public debate is still open, it should be emphasized that a psychiatric assessment and interview should be systematically provided to any person requesting medical assistance to die or commit suicide. It is the commitment of psychiatrists to understand the implicit demands and unexpressed motives underlying this request which have strong links with the unique life-events and emotional experiences of the person. The psychiatrist has a unique role in the contextualization of such a request.     

Évaluation du risque suicidaire. Entre analyse théorique et applications en pratique clinique

Since the mid-1990s and its recognition as a “public health priority”, suicide has remained at the centre of various mental health policies. With one of the highest suicide deaths at the European level, France is particularly impacted by this issue. The predictability of a self-aggressive act remains the main concern for a patient in suicidal crisis. The Dangerous Emergency Risk Assessment, established at the consensus conference in October 2000, marked a turning point in the analysis of suicidal risk. Through a triple evaluation corresponding to each of its three items, this tool has made it possible to better clarify the proposed therapeutic management and in particular the decision or not of a hospitalization. However, the latter remaining perfectible in its analysis, a mapping of key points at the clinical level has been proposed in this article in order to have the widest possible vision of a patient in suicidal crisis. The assessment of suicidal potential remains subject, despite everything, to a part of improbability. As such, a brief hospitalization in the context of the suicidal crisis has all its interest whether in front of a suicidal person or in front of a suicidal person, this in the absence of a decompensated psychiatric pathology, in order to allow a “distance” from the anxiety-provoking environment and to create a bond of trust facilitating outpatient work.