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Letter to the Editor

Sudden Death in Psychiatric Patients Is Multifactorial

Josef Finsterer, MD, PhDa; Ana C. Fiorini, MDb,c; Carla A. Scorzad; and Fulvio A. Scorza, MDd

Published: November 17, 2020

See reply by Manu and article by Manu et al

To the Editor: With interest, we read the article by Manu et al1 about a retrospective study on the causes of and risk factors for sudden death in a cohort of psychiatric patients dying suddenly (< 1 h witnessed, < 24 h unwitnessed) during a period of 26 years in a single US center. The authors identified 100 patients experiencing sudden death over the observational period, among whom the cause was identified in 48 cases. In 52 patients, the causes of sudden death remained unexplained. We have the following comments and concerns.

The main shortcoming of the study is its retrospective design. Since patients experiencing sudden death were not investigated postmortem according to a mandatory protocol, some causes of sudden death may have been missed. Furthermore, it is unclear if all 100 included patients had undergone autopsy, genetic tests, and toxicologic investigations.

Surprisingly, the prevalence of sudden death continuously increased over 26 years. Was this finding due to increasing awareness of the condition or due to change in definition of sudden death? Was the same definition applied during all 26 years?

A further shortcoming of the study is that a number of risk factors for sudden death were not considered. These include smoking, hereditary cardiac or neurologic disease, Takotsubo syndrome, noncompaction, pulmonary disease (including neurogenic pulmonary edema), and non-antipsychotic drugs.

Interestingly, no embolic strokes were identified as cause of sudden death, although it is conceivable that some of the 100 patients had atrial fibrillation, severe heart failure, dilated cardiomyopathy, noncompaction, patent foramen ovale, or Takotsubo syndrome, which are all conditions associated with intraventricular thrombus formation and thus represent a high risk for cardioembolic stroke. We should know if there was truly no embolic stroke responsible for sudden death and if these common causes were ruled out as possible causes of sudden death.

Missing is an extensive family history to determine if there were any indications for hereditary disease associated with an increased risk for sudden death, such as hereditary ventricular arrhythmias, cardiomyopathy, noncompaction, or genetic epilepsy. How many of the 100 patients had undergone echocardiography and electrocardiography prior to sudden death, and which abnormalities were found? Previous electrocardiographic, echocardiographic, and cerebral magnetic resonance imaging (MRI) findings would be particularly interesting for the 52 patients with unknown cause of sudden death.

In 2 patients, sudden death was attributed to myocarditis.1 We should know if myocarditis was diagnosed by endomyocardial biopsy or by cardiac MRI. Which of the findings were via cardiac MRI, and which were via biopsy?

Brain hemorrhage is nonspecific. We should know if the authors mean intracerebral mass bleeding or subarachnoid bleeding. It should be indicated if bleeding was diagnosed on autopsy or according to postmortem imaging.

We also should know why the inclusion of patients was restricted to those under 74 years of age. Patients aged 74 years or older may die suddenly as well.

Overall, this interesting study has a number of shortcomings, which should be addressed before final conclusions are drawn. The spectrum for causes of sudden death is much broader than considered in this retrospective review. Missing are an extensive family history, genetic tests, and consideration of a number of acquired diseases that may be responsible for sudden death.


1.Manu P, Kane JM, Correll CU. Sudden deaths in psychiatric patients. J Clin Psychiatry. 2011;72(7):936-941. PubMed CrossRef

Josef Finsterer, MD, PhDa

Ana C. Fiorini, MDb,c

Carla A. Scorzad

Fulvio A. Scorza, MDd

aKrankenanstalt Rudolfstiftung, Messerlin Institute, Vienna, Austria

bPrograma de Estudos Pós-Graduado em Fonoaudiologia, Pontifí­cia Universidade Católica de São Paulo (PUC-SP), São Paulo, Brasil

cDepartamento de Fonoaudiologia, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, Brasil

dDisciplina de Neurociência. Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, Brasil

Published online: November 17, 2020.

Author contributions: J.F.: design, literature search, discussion, first draft, critical comments. A.C.F., C.A.S., and F.A.S.: literature search, critical comments, final approval

Potential conflicts of interest: None.

Funding/support: None.

Additional information: The study was approved by the institutional review board in Vienna.

J Clin Psychiatry 2021;82(1):20lr13623

To cite: Finsterer J, Fiorini AC, Scorza CA, et al. Sudden death in psychiatric patients is multifactorial. J Clin Psychiatry. 2021;82(1):20lr13623.

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© Copyright 2020 Physicians Postgraduate Press, Inc.

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