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.
Are you confident that the infection was a cause of her death?
No. She had been taking antibiotics, and there is no sign of the infection advancing in its effects to damage her organs and their ability to function.
How important is the sheer number of pills she was taking?
Unexpected death, involving pills prescribed and not is far more common in folks who have a number of medicines in their system. Effects on the metabolism of medicine also influence how strongly one is impacted by a particular prescription. This is precisely why we, as psychiatrists and physicians, strongly counsel our patients to avoid ingesting alcohol or other central nervous system depressants while they are taking what we have prescribed.
Many have expected her to be found with methadone or other opiates in her system, and she was not? How significant is that?
If Anna Nicole Smith were in pain, for an abscess in her buttock, she would have been in more discomfort for not being on methadone. Pain management is that much more difficult in persons who have a history of abuse of opiate medicines, including the use of methadone, when no such medicines are available. Tylenol may be helpful, but pain management is that much more of a problem. Pain, especially if no methadone was available to her, may have contributed to her desire to sedate herself.
What is the reason suicide is less likely?
Smith was making plans for the future and had taken the initiative of a trip. If she were directing the administration of injections and pills that she took for longevity, this would demonstrate future directed thinking. There was no suicide note left. Her depressive symptoms were not prominent in the day preceding her death.
Does that mean suicide is not possible?
No. Anna Nicole Smith was an impulsive person whose drug use was impulsive as well. Many suicidal or parasuicidal gestures are inspired by impulse. Furthermore, many suicide attempts occur when a person is feeling more energetic and mobilizes the initiative to act on a suicidal impulse. The three benzodiazepines she took reflect that she was certainly concerned about managing anxiety, or merely keeping herself sleeping. Furthermore, there is no explanation for why Anna Nicole Smith was inclined to keep herself in bed and asleep all day, when her physical condition had been noticeably better the day before. Were she to have been in significant pain from an abscess and in withdrawal from methadone, her mood would have been more unpleasant as well. Chronic pain is associated with suicidal actions, but that is chronic pain. The point that there was chloral hydrate left in the bottle meaning that she was not suicidal is not necessarily so. Not every suicidal pill taker ingests the entire bottle.
How could this question be further pursued?
In my professional experience, I would be interested in learning about any previous suicide attempts, how they happened, why they were not successful attempts. If pills were ingested, how many? Was she one to ingest the whole bottle in her previous suicide attempts? Was she aware of the more toxic potentials of the medicines she had taken? Also, if there were accidents in which she almost died, to what degree did they involve actions she took, intentionally or carelessly, while intoxicated with something affecting her central nervous system?
What is the reason that murder is not likely?
Murder by Anna Nicole Smith being overdosed by another is less likely because the Broward medical examiner found no dramatic overdose. However, we still have no answers as to why she took chloral hydrate during the day, why she took more chloral hydrate than she would normally have, and why she had ingested a sleeping medicine when she was so tired to begin with. There are still no witnesses to her ingesting chloral hydrate.
There have been comparisons to Marilyn Monroe's death from a combination of chloral hydrate and barbiturates. Does that have any significance to you?
Barbiturates act in the same way as benzodiazepines. The irony of the similarity of death, physiologically, is eerie. But anyone close to Anna Nicole Smith and her own identification with Marilyn Monroe would know these facts and about these medicines. I would be curious to know any history of "near-misses" -- intoxications she could not account for, unexpected hospitalizations, problems with long sedations that were reported by her staff and observers in the past. Anyone with a homicidal agenda could have intoxicated her with drugs in the past, not successfully enough to kill her. As for chloral hydrate, again, I would be interested to know the history of her use of this medicine in the past and others' registered concern or discussion about it, given its role in Marilyn Monroe's death. This has relevance to consideration of suicide as well.
What are some of the other questions would you be asking at first blush, having reviewed Dr. Perper's press conference?
Who prescribed each of the medicines, and how much did they prescribe?
What was the reason she was taking prescriptions from several doctors?
If she had a personal physician who was a psychiatrist, what was the reason that others were prescribing her medicines, or that this psychiatrist was not aware of these prescriptions?
How much chloral hydrate was she prescribed?
Was it prescribed to her or to someone else?
Who would customarily give her her medicines?
Why had she taken so much chloral hydrate when she had already been taking more conservative doses the night before?
Why did she not go to the hospital for her infection, when she consented to others placing her in an ice bath?
When did she ingest the chloral hydrate?
How did she ingest it?
What was the reason she took the medicine in the morning?
How much chloral hydrate would the amount of metabolites in her system have been consistent with?
What would have been the latest that she would have taken this medicine in order that she would have no chloral hydrate in her stomach, but only its metabolites?
How was psychiatrist advising her to take the meds?
How aware was she of the toxic potential of chloral hydrate?
How aware was she of Marilyn Monroe's death from chloral hydrate?
Who was prescribing her Ativan?
Who took her off an antidepressant?
Or was she prescribed an antidepressant that she was not taking?
If she was in pain, what was the reason she stopped taking the Methadone two days before?
Did she have access to Methadone?
Is there any possibility that Methadone withdrawal contributed to her discomfort?
What financial transactions have been accessible, relative to the time of her death?
What happened to the computers that were reported stolen, from the Bahamas?
Did the medical examiner and police have an opportunity to view those files as well?
Dr. Michael Welner is chairman of the The Forensic Panel, a national forensic science practice. Dr. Welner, an associate professor of psychiatry at New York University School of Medicine, is also researching an evidence-based measure, the Depravity Scale (www.depravityscale.org ), which invites Americans to participate in surveys that are being used to help develop a legal standard of what represents the worst of crimes.