Introduction
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease involving almost every organ in the body and has a broad spectrum of clinical manifestations. Neuropsychiatric SLE (NPSLE) is a severe complication of SLE presenting with various symptoms that include depression, psychosis, and seizures. The reported prevalence of NPSLE varies from 6% to 91%.(1)
Filicide is the deliberate killing of a child by a parent. Understanding the causes of this crime and identifying the risk factors leads to improved intervention and prevention strategies. It is against this background that we present a case of a patient with NPSLE who committed filicide.
Case report
Ms. M is a 37-year-old married woman with one surviving child. She is a credit analyst and has a Master's degree.
Ms. M was referred in July 2021 for psychiatric observation in terms of section 79 (2) of the Criminal Procedure Act. She is alleged to have murdered her two children (aged 8 and 2 years) in November 2020 at their family home. She was found two days after the offence, lying in bushes near her home with evidence of a non-fatal suicide attempt.
Ms. M was diagnosed with SLE in January 2018 during her third pregnancy while following up at a private healthcare facility. She initially declined immunosuppressant therapy due to her pregnancy and breastfeeding. In May 2019, she was admitted with a severe multisystem flare that included coronary, pulmonary, and skin vasculitis, thromboembolic disease, haemolytic anaemia, and neuropsychiatric lupus with migraines and depression. She was treated with intravenous solumedrol and cyclophosphamide and then commenced on chloroquine, mycophenolate mofetil, and prednisone. She was also referred to a psychiatrist who diagnosed her with a major depressive episode and prescribed escitalopram. There was poor adherence with a limited clinical response to this agent.
In September 2019, Ms. M was admitted to a psychiatric facility with auditory hallucinations, episodic behavioural change, and repetitive abnormal movements (blinking, twitching, and stuttering). She was diagnosed with psychogenic nonepileptic seizures following three normal surface EEGs. She continued follow-up with the psychiatrist and was maintained on an antidepressant. She was placed on temporary incapacity leave and failed to return to work in June 2020.
In November 2020, Ms. M was admitted with a right temporal lobe haemorrhagic stroke that was confirmed on a magnetic resonance venogram of the brain. This was managed conservatively, with no changes to her psychiatric or rheumatology medication. The antidepressant escitalopram was the only psychotropic medication prescribed. She was discharged ten days before the offence. Post-discharge, she reported worsening of her depressive and psychotic symptoms and an inability to care for herself and her children.
Ms. M's account of events surrounding the offence reveals that she was severely depressed with derogatory auditory hallucinations and nihilistic delusions, as well as episodes of confusion and disorganised behaviour. She has maintained amnesia for the offence.
Ms. M has no forensic history and no history of substance use. Her premorbid functioning indicated long-term employment positions, and she had a stable relationship history.
The offence occurred on the background of neuropsychiatric manifestations of SLE. This includes a depressive disorder, a psychotic disorder, and focal epilepsy. During her forensic psychiatric observation, Ms. M was found not fit to stand trial and not criminally responsible. She was subsequently declared a State patient under section 42 of the Mental Health Care Act of 2002.
Discussion
Although filicide has been studied extensively, it remains difficult to categorise. The original classification system by Resnick in 1969 focused on motives.(2) Further schemes included the source of the impulse to kill, clinical situations, and psychiatric illness. More recent studies have taken a multilevel approach, looking at numerous factors that include the offender's mental health status, criminal history, and substance use history, as well as the family's social situation.(3)
Putkonen et al., in 2016, proposed a classification system that identified five subtypes of filicide.(3) It is the subtype of Prosocial, Psychotic Parents that is of most relevance in this case. These individuals are more likely to be older, married, and have a higher level of education but be unemployed at the time of the crime. The most common motive in this class is psychotic, followed by extended suicide. There is usually no previous record of family violence or dealings with authorities. The offence is usually not anticipated.
Studies have indicated a link between maternal filicide and severe mental disorders, with depression and psychosis being reported the most often.(4) In addition, many offenders have come to the attention of psychiatrists or other health professionals before the offence. A review by Flynn et al. revealed that 20% of perpetrators had previous contact with mental health services and 12% within a year of the offence.(4) It has also been shown that although maternal mental illness is highly prevalent, severe mental illness is rarely identified before the offence.
We found only one similar case report of a woman with SLE and psychosis who committed filicide.(5) She presented with delusions, auditory and visual hallucinations as well as disorganised behaviour. The accused was, however, only diagnosed with SLE after the offence. This psychiatric disorder with comorbid SLE may have precipitated the offence.
NPSLE can present with psychosis and depression, which represents a particularly high-risk group.(4) The frequency of seizure disorders in NPSLE is 7%–20%.(1) Certain types of epilepsy may be underdiagnosed. Frontal lobe hypermotor seizures are not always associated with changes on a surface EEG and are often misdiagnosed as psychogenic nonepileptic seizures.(6) Hence, NPSLE can present with severe mental disorders that might increase the risk for serious and violent offences, in this case, filicide.
Research into filicide emphasizes the need for prevention strategies, and professionals should be vigilant about identifying those parents at risk.(3–5) Filicide risk should be assessed systematically and include questions about thoughts or fears of harming their children. A depressed or psychotic parent must be evaluated for thoughts of suicide, extended suicide, and delusions involving their children. Psychosocial stressors, coping skills, and feeling overwhelmed should also be considered. A low threshold for hospitalisation should be considered, especially for mentally ill mothers of young children.