The finding: The authors describe a retrospective review of 3,032 intentional self-poisonings occurring over 15 months harvested from a shared toxicology database and a prospective 13-month study of 655 intentional overdoses from a single large inpatient toxicology practice. Over-the-counter (OTC) analgesics were involved in roughly a quarter of each population; sedative-hypnotics, antidepressants, antipsychotics, anticholinergic/antihistaminic agents, opioids and muscle relaxants were less frequent but nonetheless commonly selected. Most patients selected CNS-active agents; less than 10% of the prospective group overdosed solely on non-CNS-active medications or substances. Although overdose with more than one agent occurred with relative frequency, it was uncommon for patients in the prospective study to report they had taken “all available medications.” Comorbid alcohol intoxication was recorded in 13.5% of the retrospective review and 18.8% of the prospective study.

A fascinating finding of the prospective study was that although only 5.2% (33) of the 632 patients with self-poisoning who were subsequently queried regarding suicidal ideation endorsed ongoing suicidal ideation while hospitalized for management of their overdose, the vast majority of these (29) were individuals who experienced no significant alteration in consciousness as a result of their overdose. By contrast, of the 583 post-overdose patients who experienced delirium, profound sedation, and/or coma, only 4 endorsed active suicidal ideation after regaining sufficient cognitive clarity to engage reliably with the study physicians.

Strength and weaknesses: This review provides an uncommon overview of which medications and substances patients chose for self-poisoning, underscoring that individuals tend to choose what is available and commonly select CNS-active agents. The retrospective review provides a broad overview (almost exclusively North American) whereas the prospective study enabled more careful clarification of agents and the unique opportunity to inquire about persistent suicidal ideation. The retrospective registry did not yield consistent demographic information and medications were sometimes lumped together in broad categories; follow-up information on the patients in the retrospective study was not available. In the prospective study, there was insufficient opportunity to further explicate the details of the patients’ pre-overdose mindset and intent, their perception of the likely toxicity of the substances ingested, and the choices available to them prior to the overdose.

Relevance: The very low incidence of persistent suicidal ideation in overdose patients who experience altered consciousness as a consequence of their self-poisoning invites careful consideration of the authors’ query whether many suicidal patients may be in pursuit of an altered state of mind—or escape from their intolerable frame of mind—rather than death per se. Conversely, particular vigilance and thorough exploration of the patient’s perception of self and the future is essential in those patients who traverse an overdose with preserved consciousness, given the high incidence of persistent suicidal ideation in this group.