WARNING: This story discusses suicide and suicidal ideation.

""My daughter, in a 10-minute telephone appointment that she took at work, was prescribed 30 [pills]."

After her daughter's death by suicide, a Kitchener, Ont., mom is petitioning for a formal policy that would alert family members or caregivers when a loved one is put on new psychotropic drugs. 

Louise Carter's daughter, Madisyn Solomon, died on April 13, 2021, after a mental health crisis.

 
Solomon, 27, had been on various psychotropic drugs, ones that affect a patient's mind and behaviour. They are widely prescribed and can include antidepressants, anti-anxiety medications, anti-epileptic drugs, mood stabilizers, stimulants and anti-psychotic medications.

Many of the drugs come with warnings of an increased risk of adverse effects — including suicide and suicidal ideation (thoughts) — when a patient begins a new treatment and dosages increase.

In 2020, her family said, Solomon struggled after the death of a close friend and was prescribed an anti-depressant that resulted in the adverse reaction of suicidal ideation and being taken off the medication. She also turned to drugs and alcohol.

Over a month in 2021, Solomon was prescribed several different psychotropic drugs, attempted suicide, was hospitalized, diagnosed with a substance mood disorder and discharged. Two weeks after being discharged from a Kitchener hospital, Solomon killed herself.  

"She had an adverse reaction to the drugs her family doctor put her on that landed her in the hospital. Then she was put on more drugs in the hospital," Carter told CBC News about her daughter, a talented hairdresser. 

"That led to her death by suicide"

After Solomon was discharged on March 30, she went to stay with her father, but Carter said the family wasn't advised of the new diagnosis or that Solomon was put on new medications and higher dosages. 

Unaware of the medical risks, Solomon's father went to work on April 13 as usual. He returned that afternoon to find her dead.

Testing by the coroner, and requested by the family, detected high levels of a new psychotropic drug she had been prescribed two weeks before her death, although cause of death was not by an overdose. 

Carter feels if the family had been made aware of the prescription change, her daughter might still be alive.

"He had no idea," said Carter. "Otherwise he would have checked in on her. We would have [taken] her back to the hospital." 

Mom wants notice of patients' meds changes
Carter said she's familiar with the idea of a psychotropic drug policy. She's a dental assistant in Kitchener and her office has formal policies and procedures for patients. 

"We prescribe Lorazepam for some anxious patients. We give one one-milligram pill," explained Carter. 

"Our policy is that you have to arrive at the office an hour before your appointment, we take your blood pressure. You also have to have a caregiver in place that has agreed that they will watch you for 48 hours. This is [just] for one pill. 

"My daughter, in a 10-minute telephone appointment that she took at work, was prescribed 30 [pills]."

https://www.cbc.ca/news/canada/kitchener-waterloo/madisyn-solomon-madi-s-law-depression-1.6823221