Forensic Psychiatrist's Evaluation of Anna Nicole Smith's Cause of Death

March 26, 2007 — -- Dr. Michael Welner is a forensic psychiatrist who has consulted on cases of questionable death. He has been following the death investigation and forensic issues of Anna Nicole Smith's death as a special consultant to ABC News, including the Broward Medical Examiner's press conference and report.

What are you most surprised about in this case?

That there was no antidepressant medicine in her system, despite her history of depression. She was on Topamax, a mood-stabilizing medicine, but her dose is unknown, and Topamax can be prescribed for other reasons as well.

How is it so much harder for suicide and accident to be distinguished?

Because Anna Nicole Smith was an impulsive person who would, by accounts of others, "gulp" her pills and prescriptions. Irresponsible behavior with Valium, Klonopin, and Ativan -- three sedatives found in her system -- did not kill her. But that is because these three medicines are far easier to take erratically and in overdose without fatal repercussions. Chloral hydrate needs to be more carefully taken, or an overdose can be lethal. The Broward County medical examiner found that Anna Nicole Smith had "high" amounts of chloral hydrate metabolites in her system. Not high enough on their own to be necessarily lethal, but high.

What is the significance of her having other medicines on board?

Ativan, Klonopin and Valium are all central nervous system depressants. So is Benadryl. At higher amounts, these drugs depress respiratory centers and circulatory centers that give one the automatic drive to breathe, and for the heart to pump. At some point, under heavy intoxication, those centers are essentially slowed down to the point of stopping altogether. Chloral hydrate's effects on the central nervous system are similar to those of benzodiazepines. Therefore, if there were central nervous system effects of chloral hydrate, they would have been additive to the effects of not one, but three benzodiazepines and Benadryl already affecting her brain. A heavy dose would then have been more understandably lethal.

Is it possible that the medicines Anna Nicole Smith had taken earlier could have contributed to her accidental overdose?

If Anna Nicole Smith self-administered the chloral hydrate that killed her, her fatigued mental state of the morning may have contributed. As she had the shorter-acting Ativan, along with the long-acting Valium, Klonopin in her system acting together, these benzodiazepines in combination could most certainly increase her confusion. In the setting of being less mentally alert, one could conceive of her inadvertently ingesting excess chloral hydrate, perhaps even multiple ingestions, to the end that she suffered its toxic and fatal effects.