Salty Despair: An Adolescent’s Suicide Attempt through Salt Overdose

Introduction

Ingestion of a large amount of salt in a short period of time can lead to significant hypernatremia, neurological damage, and death.¹ Although intentional salt overdoses are a very uncommon method for attempting suicide, there have been documented cases throughout history, especially in ancient China where it was once considered a traditional suicide method.² More recently, rumors of videos circulating on social media sites discussing how to kill yourself using table salt have been brought to our attention via an adolescent female presenting to a psychiatric hospital after an intentional salt overdose.

Case History

An adolescent female with no significant past medical history presents to the Emergency Department after a suicide attempt via ingestion of kosher salt mixed with water. Patient reports consuming around four tablespoons of salt but is unsure of exact quantity. The patient learned about attempting suicide using salt from TikTok, a very popular short-form video distribution platform. The patient admits to previous non-suicidal self-injury (NSSI) by burning her skin with a lighter, although denies any prior suicide attempts and has no previous psychiatric diagnoses. Family history includes substance use disorder in the patient’s father and multiple maternal relatives with anxiety and depression. The patient’s recent suicide attempt was precipitated by multiple factors including recent arguments with her mother, as well as a sexual assault with an ex-boyfriend that occurred two to three weeks prior. The patient endorses flashbacks to the recent sexual trauma as well as increased sadness and hypersomnolence. After consuming the salt, the patient messaged a friend about the suicide attempt who then contacted police for a wellness check. She was transported to the emergency department via ambulance approximately 45 minutes after the salt ingestion.

Symptomatology

Per patient report, after consuming the salt she very quickly experienced a burning sensation in her throat and stomach, which was then followed by headache, dizziness, and nausea, but no vomiting. She also reports going in and out of consciousness and she does not remember the ambulance ride to the hospital. Per EMS report, the patient had red eyes, altered mental status, and was complaining of stomach pain. EMS vital signs documented as BP of 139/88, HR of 103 bpm, and SpO2 of 95% on room air. Emergency room triage noted a “dazed” appearance and slight stumbling when walking. The patient’s mother reports that the patient was very thirsty before and during the ambulance ride and drank four or five large cups of water. Approximately two hours after the ingestion of salt, Emergency Department physicians noted that the patient was fully alert and oriented with stable vitals and no ongoing pain or symptoms besides depressed mood and suicidal ideation.

Diagnosis and Treatment

The patient was medically cleared in the Emergency Department and transferred to the child and adolescent inpatient psychiatric unit for acute crisis stabilization. Labs obtained on the psychiatric unit approximately 13 hours after initial salt ingestion revealed normal blood sodium (139 mmol/L), high normal chloride (107 mmol/L), and a slight elevation in BUN to Creatine ratio (21.3) suggesting mild dehydration. CBC with differential was all within normal range. The absence of hypernatremia may be due to the to the large amount of water the patient consumed after the salt ingestion or may be due to the delay in obtaining a blood work. It may also suggest that the patient consumed less salt than initially reported. The patient’s mother clarifies that the spoon the patient used for the salt was part of a flatware cutlery set and was the smaller of the two spoon sizes in the set. The spoon was likely a dessertspoon, which is in between a standard teaspoon (6 g of NaCl) and a tablespoon (18 g of NaCl) indicating the patient consumed approximately 12 g NaCl per spoonful, or 48 g total.³

The patient denied any ongoing symptoms of nausea, dizziness, or headache, and reported normal thirst and urination. She was diagnosed with major depressive disorder and post-traumatic stress disorder and started on 10 mg daily Fluoxetine (Prozac). The medication was well-tolerated, and the patient reported an early decrease in flashbacks to the past sexual trauma. She was discharged home after a six-day admission with no ongoing suicidal ideation, and referrals were made to continue with outpatient psychiatry and mental health therapy.

Discussion

Intentional salt overdose is an uncommon method for attempting suicide but can be extremely harmful and potentially fatal due to the resulting hypernatremia and CNS damage. Neurological symptoms stem from rapid fluid shifts in brain tissue causing cell shrinkage which can lead to brain hemorrhages in the most severe cases. Other symptoms include extreme thirst, hyperreflexia, confusion, seizures, and coma.⁴ The potential for harm in these cases is exacerbated by a lack of public awareness which may lead to delays in care. If a patient discloses a salt overdose to a loved-one they may be less likely to call for emergency services as they otherwise would for a prescription drug overdose. In a similar vein, not all healthcare providers are aware of the severity of salt overdoses, which could further delay treatment. We use this case to not only highlight the signs and symptoms of salt overdose, but to also bring awareness to fellow healthcare providers.

One systematic review of fatalities related to acute salt ingestion found that a lethal dose of salt in young children was less than 5 teaspoons (30 g NaCl) and a lethal dose in adults was less than 4 tablespoons (72 g NaCl).⁵ Of the 35 fatalities in this review, only three of them appear to be related to psychiatric causes and were listed as “exorcism rituals” occurring in Spain, Israel, and France. Another systematic review that included 15 cases found three cases involving intentional consumption of salt as part of a suicide attempt, all of which occurred using soy sauce in Japan.³ One case in the United Stares in 2013 involved a college fraternity hazing ritual where a 19-year-old ingested 1 qt of soy sauce and was in a coma for three days with significant hypernatremia (max blood sodium of 191.3 at 4.5 hours post ingestion). Remarkably this patient recovered fully with no lasting neurological effects.⁶ Intentional salt overdoses are historically less common in the US, however this case highlights the potential for a rise in salt overdoses due to videos posted on TikTok and other video platforms. A Google Video search on “eat salt challenge” on 8-25-24 returned over 6 million results, and a preliminary search on TikTok for “salt overdose” revealed multiple videos ranging from dangers of salt-water consumption in pets to videos of people mixing salt with water with no further explanation.

Healthcare providers as well as parents, guardians, and teachers should be aware of the dangers of intentional salt overdoses, especially with the idea potentially circulating on social media. Although this case has a favorable outcome, fatal hypernatremia could have occurred. To our knowledge, there are no recent case reports on intentional salt overdose in adolescents in the United States, and our hopes are that this report brings awareness to the dangers and easy access of this lethal means stored in nearly every kitchen.