Homicide-suicide: current evidence, risk assessment, and medico-legal implications in forensic psychiatry

Homicide-suicide is a rare but highly impactful form of lethal violence characterized by the convergence of suicidality, interpersonal aggression, and psychopathology. This narrative review summarizes current evidence regarding epidemiology, major subtypes, interpretative models, psychiatric and relational risk factors, risk assessment strategies, prevention approaches, and medico-legal implications within forensic psychiatry. Available data suggest that homicide-suicide represents a distinct phenomenon rather than the mere succession of homicide and suicide, most frequently occurring in intrafamilial contexts, particularly in intimate partner violence. Depression, suicidal ideation, relational crisis, substance misuse, warning signs, and access to lethal means emerge as the most relevant clinical and contextual variables. From a forensic psychiatric perspective, risk assessment requires an integrated and dynamic approach combining clinical judgment, structured instruments, collateral information, and evaluation of relational escalation. Preventive strategies include early identification of high-risk configurations, restriction of access to lethal means, interagency collaboration, and timely protective interventions. Homicide-suicide therefore represents a major clinical and medico-legal challenge, highlighting the need for specific operational protocols and closer integration between suicide prevention and violence prevention frameworks.