Fatal Choking in Patients with Psychiatric Disorders: A Systematic Review of Forensic Evidence

Background: Fatal choking is a preventable cause of mechanical asphyxia that occurs more frequently among individuals with psychiatric disorders due to behavioural abnormalities, neurological comorbidities, and medication-related swallowing impairment. This review aims to highlight the clinical and forensic factors contributing to fatal choking and the importance of a multidisciplinary approach to its investigation. Methods: A systematic review was conducted according to PRISMA guidelines by searching PubMed, Scopus, and Web of Science. In total, 25 studies describing fatal choking in adults with psychiatric disorders and including medico-legal investigations were selected and analyzed. Results: Schizophrenia was the most frequently reported psychiatric condition, followed by bipolar disorder, depression, and dementia. Antipsychotics, antidepressants, anxiolytics, and other psychotropic drugs were recurrently associated with dysphagia and reduced airway protective reflexes. Food boluses represented the predominant obstructive material, although several unusual foreign bodies were documented. Virtopsy, autopsy, histological, and toxicological investigations consistently proved essential for confirming airway obstruction, reconstructing the mechanism of death, and identifying contributing clinical and pharmacological factors. Conclusions: Fatal choking in psychiatric patients is a multifactorial event requiring early risk assessment, preventive strategies, and comprehensive forensic evaluation to improve patient safety and ensure accurate determination of the cause of death.