# Forensic postmortem findings for sudden unexplained death in schizophrenia: case series and literature review

## TL;DR

This study examines sudden unexplained deaths in people with schizophrenia, finding that heart issues and antipsychotic drugs may be involved.

## Contribution

The study provides a detailed case series and literature review of sudden unexplained deaths in schizophrenia patients, highlighting autopsy findings and antipsychotic drug presence.

## Key findings

- Cardiac pathology was the most frequent postmortem finding in sudden unexplained death cases in schizophrenia.
- Olanzapine and clozapine were the most commonly detected antipsychotics at therapeutic levels in postmortem analyses.
- Overweight or obesity was reported in nearly 70% of cases, suggesting a possible link to antipsychotic use and heart pathology.

## Abstract

There are currently limited autopsy-based studies on sudden unexplained death in patients with schizophrenia (SDU-SCZ).

We summarized the demographic data, autopsy characteristics, and postmortem antipsychotics result for a total of 152 SUD-SCZ decedents, encompassing three cases from our forensic center and 149 literature-reported autopsy cases.

The SUD individuals were found in adults at all ages, ranging from 19–86 years old, with a male-to-female ratio being 94: 58. A total of 106 patients (69.7%, 106/152) were documented to be overweight or obese. Autopsy findings were available in 77 of the 152 cases. The most frequent postmortem pathology was cardiac (46.8%, 36/77), of which unclassified cardiomegaly, focal myocardial fibrosis, and mild coronary atherosclerosis were the most common manifestations, documented in 11 (14.3%), 8 (10.4%), and 5 cases (6.5%), respectively. Data on postmortem antipsychotics were available in 74 of the 152 cases, of which 65 (87.8%, 65/74) were tested positive of any antipsychotic drug, all at therapeutic levels. Olanzapine and clozapine were the most commonly prescribed antipsychotic drugs, documented in 18 cases (24.3%, 18/74) and 16 cases (21.6%, 16/74), respectively. In these SUD-SCZ individuals, the exact cause of death remained unexplained after comprehensive autopsy examination and postmortem antipsychotics analysis.

Linking premorbid conditions (e.g. overweight or obese) to antipsychotics medication histories and postmortem myocardial pathologies would facilitate a more accurate determination and interpretation of the cause of death. Forensic investigation is useful for developing preventive strategies for this vulnerable population.