After daughter's suicide, this mom wants caregivers notified when loved ones get psychotropic meds

WARNING: This story discusses suicide and suicidal ideation.

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." 

WATCH | Louise Carter says she wants to create a legacy so daughter Madisyn didn't die in vain:

After her daughter's suicide, this mom wants caregivers notified when loved ones get psychotropic meds

2 years ago

Duration 8:14

After her daughter's death by suicide, a Kitchener, Ont., mom is petitioning for a formal policy that would alert caregivers or family members when their loved ones are prescribed psychotropic drugs.

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]."

Carter said she wants to see a family member or caregiver of the patient's choice advised that they've started these drugs — or that the dosage has been increased — so they can help monitor and keep an eye out for suicidal behaviours.

"It is a big decision as to whether you take psychotropic drugs or not," said Carter. "I feel at the point when the doctor and the patient have decided they're now going to embark on a psychotropic drug, it's at that point that the [policy]  should come into play.

"It would have saved my daughter's life. I don't feel that asking patients ... to monitor themselves is feasible."

Good idea, hard to implement: experts

The idea has some merit, said Dr. Carlos Lalonde, a psychiatrist who's also chief of staff and president of Homewood Health Centre — a mental health and addictions service provider in Guelph.

It would be complicated to implement, but the biggest hurdle would be consent from the patients involved, he said. 

"If a capable person says you can't share the information with my family member, then you're not able to disclose diagnosis, specific treatments — even if there are common severe potential side-effects, including a potential increase in suicidality," Lalonde told CBC News. 

That changes if there's imminent risk. But prescribing new drugs or increasing the dosage wouldn't generally meet that bar, he said.

However, if the patient would consent, Lalonde said, ensuring family members or loved ones are keeping a watchful eye makes sense.

"Any opportunity to enhance awareness and involvement is a positive thing and could potentially improve outcomes. Is this specifically the right choice, the right way to go about it? I don't know."

Tejal Patel isn't sure either.

Patel, a pharmacist and clinical associate professor at the University of Waterloo's school of pharmacy, said the risk of adverse reactions like suicidal ideation varies greatly within the different categories of psychotropic drugs and even from one subtype to another. 

"Right now we do a lot of general advising: generally, this medication causes nausea, headaches, cramps, etc. We don't usually tell people what the potential increase in the risk is, based on the person in front of us — because it's a very difficult thing to do."

Factors including medical history, age, gender, home life and other medications can all have an impact on a patient's risk. 

"A safety waiver that addresses all of those things and makes it person-centred — it's not that it's not doable. It's just going to be a very difficult challenge," said Patel. 

Patel and Lalonde agree the idea of more and better communication between patients, doctors and care providers is an excellent idea. 

"Anything we could do that will improve outcomes, that will enhance communication with family, when you have the consent to do so, anything that will prevent horrible outcomes like suicide — I think it's good," said Lalonde. 

"This is how good change comes about."

Petition sent to health ministers

A petition bearing 3,700 signatures and a letter urge federal Health Minister Jean-Yves Duclos and nine provincial health ministers to enact what Carter is calling Madi's Law. 

CBC News reached out to Duclos's office for comment.

"The safety of Canadians is Health Canada's top priority and we extend our sincerest condolences to the families and loved ones of anyone who has suffered because of an adverse reaction to a drug," said Mark Johnson, a spokesperson for Health Canada and the Public Health Agency of Canada.

Johnson said every drug approved in Canada must have a document describing detailed information on its properties, claims, indications and conditions of use, as well as a warning of possible adverse reactions and other information for safe and effective use.

He said health-care professionals "have a responsibility to assess the benefits and the risks of the health product for each individual patient" and "to adequately inform patients about these risks and benefits ... mandating how or when prescribers counsel patients or caregivers about monitoring and reporting signs of suicidal ideation or suicidal behaviours is also a practice of medicine issue."

A spokesperson for Ontario's Ministry of Health confirmed the Carters' letter had been received and said they offered  "deepest condolences to the family during what must be a difficult time."

Carter said that if her work raises awareness but doesn't lead to legislative change, she's OK with that.

"I never win. My daughter's gone. But if I can prevent the pain of this happening to somebody else — because it is so painful — that's the motive." 

If you or someone you know is struggling, here's where to get help:

• Talk Suicide Canada: 1-833-456-4566 (phone) | 45645 (text between 4 p.m. and midnight ET).
• Kids Help Phone: 1-800-668-6868 (phone), live chat counselling on the website.
• Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.
• This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.

If you're worried someone you know may be at risk of suicide, you should talk to them about it, says the Canadian Association for Suicide Prevention. Here are some warning signs: 

• Suicidal thoughts.
• Substance abuse.
• Purposelessness.
• Anxiety.
• Feeling trapped.
• Hopelessness and helplessness.
• Withdrawal.
• Anger.
• Recklessness.
• Mood changes.