Why are people with mental illness excluded from the rational suicide debate?

Somatized or stigma? Causal attributions and emotional responses in shaping social distance towards people with mental illness, China

Background

Mental illness in China has traditionally been attributed to physical factors and somatization tendencies, which seldom result in stigma. How has this perception changed after decades of social change?

Methods

Based on the Chinese General Social Survey database in 2011, this study constructed a structural equation model to analyze the effects of causal attribution and emotional responses on social distance. The causal attributions include dangerousness, controllability, and responsibility. And the emotional responses encompass negative affect, traditional prejudice, treatment carryover, and exclusionary sentiments. In addition, higher scores indicating greater social distance, whereas a low score reflected stronger emotional responses or a greater degree of internal attribution.

Results

The results reported a high level of social distance towards people with mental illness. These findings indicated that emotional responses have a direct impact on social distance. Specifically, when negative affect, traditional prejudice, and exclusionary sentiments increase by one standard deviation, the social distance decreases by 0.497, 0.178, and 0.073 standard deviation, respectively. Conversely, as the level of treatment carryover rises, social distance increases by 0.087. Meanwhile, the causal attribution only exerts a significant indirect effect on social distance by the function of emotional causal responses.

Conclusion

The results indicated that the public attributes mental illnesses like depression primarily to psychological issues rather than somatic ones. It suggested widespread stereotypes and public stigma towards people with mental illness in China, as well as an arduous task in anti-stigma. In addition, a targeted way to address public stigma lies in changing the stereotype of people with mental illness.

Implications of psychiatric diagnosis for Voluntary Assisted Dying in Victoria

Voluntary Assisted Dying is a process whereby terminally ill patients are provided a lethal dose of medication for them to voluntarily ingest to end their life. Victoria, Australia, implemented legislation permitting Voluntary Assisted Dying for terminally ill adult patients with a life expectancy less than 6 months. Ethical dilemmas arise when terminally ill patients with a comorbid mental illness attempt to access Voluntary Assisted Dying because of the complex relationship between psychiatric conditions and suicidal ideation. This paper seeks to investigate the most ethical approach for doctors to respond to such a request by discussing objections raised in other literature to patients with a comorbid psychiatric illness aiming to access Voluntary Assisted Dying in Victoria. To answer this question, objections to terminally ill patients with a comorbid psychiatric illness accessing Voluntary Assisted Dying were found through review of literature. Discussion of these objections centred around unpacking the two historical ethical justifications for Voluntary Assisted Dying: respect for autonomy and relief of suffering. Regarding autonomy, contention focused on competency to make autonomous decisions. Not all psychiatric patients lack competency to decide about Voluntary Assisted Dying, and there are comparable competency assessments used in psychiatry today. Considering suffering, objections related to the authenticity of the intolerable nature of a patient's suffering out of concerns that it has been influenced by their condition, and that the psychiatric illness may still be treatable. However, given suffering is subjective, its perception is not lessened if the source is psychological in nature. Furthermore, it is challenging to justify a position where a patient is forced to spend the last months of their life enduring suffering that has been historically refractory to multiple, genuine treatment efforts. Not all terminally ill patients with a comorbid psychiatric disorder will lack competency to choose Voluntary Assisted Dying, and many will have genuine suffering for which they are requesting Voluntary Assisted Dying. Multidisciplinary, holistic assessments for these patients are not mandated, but would be useful to address the issues, overcome barriers to access and determine that applicants are making an authentic request.

Making a case for the inclusion of refractory and severe mental illness as a sole criterion for Canadians requesting medical assistance in dying (MAiD): a review

BACKGROUND

Following several landmark rulings and increasing public support for physician-assisted death, in 2016, Canada became one of a handful of countries legalising medical assistance in dying (MAiD) with Bill C-14. However, the revised Bill C-7 proposes the specific exclusion of MAiD where a mental disorder is the sole underlying medical condition (MAiD MD-SUMC).

AIM

This review explores how some persons with serious and persistent mental illness (SPMI) could meet sensible and just criteria for MAiD under the Canadian legislative framework.

METHODS

We review the proposed Bill C-7 criteria (capacity, voluntariness, irremediability and suffering) as well as the nuances involved in separating a well-reasoned request for assisted suicide from what might be solely a manifestation of a SPMI.

FINDINGS

In this paper, we argue against the absolute exclusion of patients with SPMIs from accessing MAiD. Instead, we propose that in some circumstances, MAiD MD-SUMC may be justifiable while remaining the last resort. Conducting MAiD eligibility assessments removes the need to introduce diagnosis-specific language into MAiD legislation. Competent psychiatric patients who request MAiD should not be treated any differently from other eligible candidates. Many individuals with psychiatric disorders will be incapable of consenting to MAiD. The only ethical option is to assess eligibility for MAiD on an individual basis and include as legitimate candidates those who suffer solely from psychiatric illness who have the decisional capacity to consent to MAiD.

An analysis of suicidal thoughts and behaviors among transgender and gender diverse adults

PURPOSE

Suicidal thoughts and behaviors (STBs) remain a pressing public health problem for transgender and gender diverse (TGD) persons. The goal of this study was to apply social-ecological and minority stress frameworks to identify individual and interpersonal-level TGD-specific STB risk and protective factors.

METHODS

This is a secondary analysis of the 2015 United States Transgender Health Survey, a comprehensive cross-sectional health assessment of a national sample of TGD adults (N = 27,658). Chi-square and Analysis of Variance (ANOVA) were used to identify bivariate correlates of 12-month and lifetime suicidal ideation (SI) and suicide attempt (SA). Logistic regression was employed to identify the strongest STB risk and protective factors across levels.

RESULTS

Sexual minority identification, racial minority identification, and having a disability were lifetime STB risk factors. TGD identity, sexual minority identification, racial minority identification (SA only), lower education, lower income, military experience, having a disability, and being uninsured were 12-month STB risk factors. Psychological distress was the most robust STB risk factor. Workplace discrimination, family rejection, healthcare discrimination, and childhood bias-based victimization were lifetime STB risk factors. All forms of discrimination and victimization (with the exception of family rejection for SI) were 12-month STB risk factors. Family and coworker support were protective factors for lifetime SA (but not SI) and all 12-month STBs. Being less out about TGD identity was a protective factor for STBs (except for 12-month SI).

CONCLUSION

Findings support social-ecological and minority stress STB risk frameworks. Recommendations are provided for a comprehensive approach to TGD suicide prevention.

Assisted dying requests from people in detention: Psychiatric, ethical, and legal considerations-A literature review

The principle of equivalence of care states that prisoners must have access to the same standard of health care as the general population. If, as recent court decisions suggest, assisted dying is not limited to people with a terminal physical illness or irremediable suffering, it might also be requested by people with severe mental illness in detention. Some of the countries with legal regulations on assisted dying also have recommendations on how to handle requests from prisoners. However, detention itself can lead to psychological distress and suicidality, so we must consider whether and how people in such settings can make autonomous decisions. Ethical conflicts arise with regard to an individual's free will, right to life, and physical and personal integrity and to the right of a state to inflict punishment. Furthermore, people in prison often receive insufficient mental health care. In this review, we compare different practices for dealing with requests for assisted dying from people in prison and forensic psychiatric facilities and discuss the current ethical and psychiatric issues concerning assisted dying in such settings.

Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders

PURPOSE OF REVIEW

Over the last 30 years, medical assistance in dying (MAiD) including euthanasia (EU) and physician-assisted death (or suicide, PAS) has become the center of a large debate, particularly when these practices have involved people with psychiatric illness, including resistant depression, schizophrenia, personality, or other severe psychiatric disorders. We performed a review utilizing several databases, and by including the most relevant studies in full journal articles investigating the problem of MAiD in patients with psychiatric disorders but not in physical terminal conditions (non-terminal, MAiD-NT).

RECENT FINDINGS

Literature has shown that a small percentage of people with psychiatric disorders died by MAiD-NT in comparison with patients with somatic diseases in terminal clinical conditions (e.g., cancer, AIDS). However, the problem in the field is complex and not solved yet as confirmed by the fact that only a few countries (e.g., the Netherlands, Belgium, Luxemburg) have legalized MAiD-NT for patients with psychiatric disorders, while most have maintained the practices accessible only to people with somatic disease in a terminal phase. Also, how to make objective the criterion of irremediability of a mental disorder; how to balance suicide prevention with assisted suicide; how to avoid the risk of progressively including in requests for MAiD-NT vulnerable segments of the population, such as minors, elderly, or people with dementia, in a productive-oriented society, are some of the critical points to be discussed. The application of MAiD-NT in people with psychiatric disorders should be further explored to prevent end-of-life rights from contradicting the principles of recovery-oriented care.

Do Doctors Differentiate Between Suicide and Physician-Assisted Death? A Qualitative Study into the Views of Psychiatrists and General Practitioners

Physician-assisted death for patients suffering from psychiatric disorders is allowed in the Netherlands under certain circumstances. One of the central problems that arise with regard to this practice is the question of whether it is possible to distinguish between suicidality and a request for physician-assisted death. We set up this study to gain insight into how psychiatrists and general practitioners distinguish between suicidality and physician-assisted death. The data for this study were collected through qualitative interviews with 20 general practitioners and 17 psychiatrists in the Netherlands. From the interviews, we conclude that physicians distinguish three types of death wishes among patients suffering from psychiatric disorders: 'impulsive suicidality,' 'chronic suicidality,' and 'rational death wishes.' To discern between them they evaluate whether the death wish is seen as part of the psychopathology, whether it is consistent over time, and whether they consider it treatable. Some considered physician-assisted death an alternative to a 'rational suicide,' as this was perceived to be a more humane manner of death for the patient and their relatives. We argue that physician-assisted death can be justified also in some cases in which the death wish is part of the psychopathology, as the patient's suffering can be unbearable and irremediable. Physician-assisted death in these cases may remain the only option left to relieve the suffering.

Compulsory Interventions in Severe and Persistent Mental Illness: A Survey on Attitudes Among Psychiatrists in Switzerland

Background: Some psychiatric patients develop severe and persistent mental illness (SPMI), which, for a variety of reasons, can be therapy-refractory. Sometimes, treatment is not considered helpful by the patients themselves and does not improve their subjective quality of life. Furthermore, many SPMI patients experience compulsory interventions such as seclusion, restraint, or treatment against their will, which can cause harm. Methods: In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about the care of SPMI patients in general, and about their attitudes with regard to compulsory interventions in particular, using three case vignettes of patients with severe and persistent anorexia nervosa, schizophrenia and depression. Results: Out of 1,311 contacted psychiatrists, 457 (34.9%) returned the completed survey. In general, 91.0% found it important or very important to respect SPMI patients' autonomy in decision making. However, based on three different clinical case vignettes, 36.8% of psychiatrists would act against the wishes of the patient with severe and persistent schizophrenia, 34.1% against the wishes of the patient with severe and persistent depression, and 21.1% against the wishes of the patient with severe and persistent anorexia nervosa, although all patients were stated to have preserved decision-making capacity. With regard to the case vignettes, 41.1% considered compulsory interventions leading to a temporary reduction of quality of life acceptable in the patient with severe and persistent schizophrenia, 39.4% in the patient with severe and persistent depression, and 25.6% in the patient with severe and persistent anorexia nervosa, although it was stated in all three case vignettes that two independent experts ascribed the patients decision-making capacity regarding their illness and further treatment. Conclusions: Many psychiatrists in our sample found themselves in an ethical dilemma between autonomy and the provision of medical care. While most respondents respect the autonomy of SPMI patients, many saw the need to perform compulsory interventions even though it was clearly and prominently stated that two independent psychiatrists had ascribed the patients in the case vignettes decision-making capacity. Further examination of these conflicting views is warranted, perhaps along with the development of guidelines for such situations.

Psychiatrie, soins palliatifs et de fin de vie : des univers (ir)réconciliables? Le cas de madame Sanchez

Contexte : En psychiatrie, la question d’offrir des soins palliatifs et de fin de vie pour ce qui serait une « condition psychiatrique terminale » ou, plus globalement, de considérer adopter une approche palliative pour des problèmes de santé mentale sévères et persistants constitue encore un tabou. Méthodologie : Cette question est abordée par l’analyse d’un cas effectuée lors d’une consultation en éthique clinique à l’aide de la méthode des scénarios d’Hubert Doucet. Il s’agit de madame Sanchez, une patiente âgée de plus de 90 ans, présentant des troubles psychiatriques, exprimant le désir de mourir par des gestes suicidaires, refusant les traitements proposés, ainsi que refusant de boire et manger. Son histoire clinique est racontée par le filtre de l’accompagnement réflexif offert en éthique clinique aux diverses parties prenantes. Résultats : L’analyse de cas, loin de répondre aux défis posés par le concept des soins palliatifs et de fin de vie en contexte psychiatrique, présente néanmoins une occasion d’en nommer les enjeux éthiques principaux : la souffrance psychique, le refus de manger et de boire ainsi que le refus de traitement, la sédation palliative et l’aide médicale à mourir, les volontés et directives médicales anticipées, ainsi que les défis clinico-organisationnels suscités par la clientèle gérontopsychiatrique. Conclusion : Les défis cliniques et éthiques demeurent nombreux pour les professionnels et les décideurs afin de répondre aux besoins de la clientèle de santé mentale très âgée. Nous appelons à un plus grand développement des connaissances sur ce thème précis.

Old and Depressed? What We Think About Ending Their Suffering—Attitudes Toward Euthanasia for Elderly Suffering From Physical Versus Mental Illness

This study aims to extend our knowledge regarding attitudes toward euthanasia. Specifically, the effect of patient’s age and illness type. 123 participants were randomly assigned to 1 of 4 groups completed the Assessing Right to Die Attitudes (ARDA) questionnaire after reading a patients age (79 vs. 29 year old) and illness type (cancer vs. depression) description. Findings revealed more positive attitudes toward euthanasia when the patient was physically ill, as opposed to mentally ill. Participants’ attitude towards euthanasia was more positive when the patient was elderly. Illness type as a function of the patient’s age did not significantly influence attitudes towards euthanasia. The results of the current study reinforce the individual influence of illness type and of patient age on attitudes toward euthanasia, and suggest additional avenues for further research regarding their combined influence.

The influence of cognitive distortions on decision-making capacity for physician aid in dying

As international laws on physician aid in dying (PAD) evolve, the question of permitting PAD in non-terminal illness, and in sole psychiatric illness, is under intense debate. In jurisdictions where PAD is permissible, certain safeguards and eligibility requirements must be met for all patients making a PAD request, and one of these requirements is that the patient have sound decision-making capacity with respect to the request. Legal criteria already exist for the determination of capacity, and they are quite similar between different jurisdictions. In current debates about the question of psychiatric PAD, one concern that has been raised is that cognitive distortions in mental disorders may affect a patient's decision-making capacity. At the same time, it has been established that all persons, with or without a mental disorder, experience cognitive distortions. If cognitive distortions are ubiquitous, it is likely that the severity and frequency of cognitive distortions is dimensional rather than categorical, between samples with and without mental illness. Furthermore, currently, there is no requirement for a formalized evaluation of cognitive distortions as part of capacity assessment for any type of medical decision, including PAD decisions. The current paper examines the literature related to cognitive distortions in mental disorders and in healthy populations. It proposes that the existence of cognitive distortions, alone, cannot be used as an argument for a blanket exclusion of psychiatric PAD. It therefore concludes that further research and ethical analysis should be undertaken to examine the impact of cognitive distortions on decision-making for consequential medical decisions, including PAD, in patients with and without mental disorders.

Rational and irrational suicide in Plato and modern psychiatry

Suicide is a complex issue that is sparking increasingly more debate in contemporary society. There is need for an open discussion on the concept of rational suicide, specifically in relation to psychiatric disorders, so as to resolve the conflict between the duty of care of psychiatrists and the autonomy of patients. To be able to conduct such a discussion in an objective manner, we must first be made aware of the potential prejudices that we harbour on the topic of suicide as a result of our societal and historical background. A historical and philosophical approach to the topic, through careful examination of the topic of suicide in the texts of Plato, helps create such an awareness.

Technology for Our Future? Exploring the Duty to Report and Processes of Subjectification Relating to Digitalized Suicide Prevention

Digital and networking technologies are increasingly used to predict who is at risk of attempting suicide. Such digitalized suicide prevention within and beyond mental health care raises ethical, social and legal issues for a range of actors involved. Here, I will draw on key literature to explore what issues (might) arise in relation to digitalized suicide prevention practices. I will start by reviewing some of the initiatives that are already implemented, and address some of the issues associated with these and with potential future initiatives. Rather than addressing the breadth of issues, however, I will then zoom in on two key issues: first, the duty of care and the duty to report, and how these two legal and professional standards may change within and through digitalized suicide prevention; and secondly a more philosophical exploration of how digitalized suicide prevention may alter human subjectivity. To end with the by now famous adagio, digitalized suicide prevention is neither good nor bad, nor is it neutral, and I will argue that we need sustained academic and social conversation about who can and should be involved in digitalized suicide prevention practices and, indeed, in what ways it can and should (not) happen.

Perceived Burdensomeness and the Wish for Hastened Death in Persons With Severe and Persistent Mental Illness

Background: In several European countries, medical assistance in dying (MAID) is no longer confined to persons with a terminal prognosis but is also available to those suffering from persistent and unbearable mental illness. To date, scholarly discourse on MAID in this population has been dominated by issues such as decision-making capacity, uncertainty as to when a disease is incurable, stigmatization, isolation, and loneliness. However, the issue of perceived burdensomeness has received little attention. Objective: The study explores the possible impact of perceived burdensomeness on requests for MAID among persons with severe and persistent mental illness (SPMI). Method: Using the method of ethical argumentation, we discuss the issue of access to MAID for persons with SPMI and perceived burdensomeness. Conclusion: Perceived burdensomeness may be a contributing factor in the wish for hastened death among persons with SPMI. MAID is ethically unsupportable if SPMI causes the individual to make an unrealistic assessment of burdensomeness, indicating a lack of decision-making capacity in the context of that request. However, the possibility that some individuals with SPMI may perceive burdensomeness does not mean that they should be routinely excluded from MAID. For SPMI patients with intact decision-making capacity who feel their life is not worth living, perceived burdensomeness as a component of this intolerable suffering is not a sufficient reason to deny access to MAID.

Attitudes toward assisted suicide requests in the context of severe and persistent mental illness: A survey of psychiatrists in Switzerland

Objective

Switzerland is among the few countries worldwide where a request for assisted suicide (AS) can be granted on the basis of a primary psychiatric diagnosis. Psychiatrists play an increasingly important role in this regard, especially when the request for AS arises in the context of suffering caused by severe and persistent mental illness (SPMI). The objective of the survey was to assess general attitudes among psychiatrists in Switzerland regarding AS requests from patients with SPMI.

Method

In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about their attitude to AS for patients with SPMI, based on three case vignettes of patients diagnosed with anorexia nervosa, treatment-refractory depression, or severe persistent schizophrenia.

Result

From a final sample of 457 psychiatrists (a response rate of 34.9%) whose mean age was 57.8 years, 48.6% of respondents did not support access to AS for persons diagnosed with SPMI, 21.2% were neutral, and 29.3% indicated some degree of support for access. In relation to the case vignettes, a slightly higher percentage of respondents supported the patient's wish to seek AS: 35.4% for those diagnosed with anorexia nervosa, 32.1% for those diagnosed with depression, and 31.4% for those diagnosed with schizophrenia.

Significance of results

Although a majority of the responding psychiatrists did not support AS for SPMI patients, about one-third would have supported the wishes of patients in the case vignettes. In light of the increasing number of psychiatric patients seeking AS and the continuing liberalization of AS practices, it is important to understand and take account of psychiatrists’ perspectives.

Euthanasia, religiosity and the valuation of health states: results from an Irish EQ5D5L valuation study and their implications for anchor values

Background

The Quality Adjusted Life Year influences the allocation of significant amounts of healthcare resources. Despite this surprisingly little research effort has been devoted to analysing how beliefs and attitudes to hastening death influence preferences for health states anchored at “dead” and “perfect health”. In this paper we examine how, inter alia, adherence to particular religious beliefs (religiosity) influences attitudes to euthanasia and how, inter alia, attitudes to euthanasia influences the willingness to assign worse than dead (WTD) values to health states using data collected as part of the Irish EQ5D5L valuation study.

Methods

A sample of 160 respondents each supplied 10 composite time trade-off valuations and information on religiosity and attitudes to euthanasia as part of a larger national survey. Data were analysed using a recursive bivariate probit model in which attitudes to euthanasia and willingness to assign WTD values were analysed jointly as functions of a range of covariates.

Results

Religiosity was a significant determinant of attitudes to euthanasia and attitudes to euthanasia were a significant determinant of the likelihood of assigning WTD values. A significant negative correlation in errors between the two probit models was observed indicative of support for the hypothesis of endogeneity between attitudes to euthanasia and readiness to assign WTD values.

Conclusion

In Ireland attitudes and beliefs play an important role in understanding health state preferences. Beyond Ireland this may have implications for: the construction of representative samples; understanding the values accorded health states and; the frequency with which value sets must be updated.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0985-9) contains supplementary material, which is available to authorized users.

Attitudes Toward Euthanasia for Patients Who Suffer From Physical or Mental Illness

This study examined whether attitudes toward euthanasia vary with type of illness and with the source of the desire to end the patient’s life. The study used a 3 (illness type: cancer, schizophrenia, depression) × 2 (euthanasia type: patient-initiated, family-initiated) between-groups experimental design. An online questionnaire was administered to 324 employees and students from a Australian public university following random assignment of participants to one of the six vignette-based conditions. Attitudes toward euthanasia were more positive for patients with a physical illness than a mental illness. For a patient with cancer or depression, but not schizophrenia, approval was greater for patient-, than, family-, initiated euthanasia. Relationships between illness type and attitudes were mediated by perceptions of patient autonomy and illness controllability. Findings have implications for debate, practices, and legislation regarding euthanasia.

Insight into the Stigma of Suicide Loss Survivors: Factor Analyses of Family Stereotypes, Prejudices, and Discriminations

Families of individuals who die by suicide report public stigma that threatens their well-being. This study used a community-based participatory (CBPR) approach to describe a factor structure for the family stigma of suicide. Candidate items (n = 82) from a previous qualitative study were presented in an online survey format. Members of the public (n = 232) indicated how much they thought items represented public views and behaviors towards family members who lost a loved one to suicide. Factor analyses revealed two factors for stereotypes (dysfunctional, blameworthy), one factor for prejudice (fear and distrust), and three factors for discrimination (exclusion, secrecy, and avoidance).

Making Sense of the Public Stigma of Suicide

Abstract. Background: Research suggests that stigma is a barrier to care for individuals who have attempted suicide. While extensive work has examined the stigma of mental illness, less research has focused on the public stigma of suicide. Existing measures of suicide stigma have lacked a conceptual foundation or have failed to include the perspectives of suicide stakeholders. Aims: This research draws on previous qualitative research with suicide stakeholders to create a measure of public suicide stigma. Method: This study used a community-based participatory research (CBPR) approach to define a factor structure for suicide stigma. The CBPR team used focus groups to generate items for each component of stigma (stereotypes, prejudice, and discrimination). Two online surveys (N = 372; N = 243) asked members of the public to rate candidate items for stereotypes, prejudice, and discrimination. Results: Analyses revealed three factors for stereotypes (weak, crazy, distressed), two factors for prejudice (fear/distrust, anger), and three for discrimination (avoidance, disdain, coercion). Limitations: Results should be confirmed in other samples and further evidence gathered on convergent, divergent, and discriminant validity. Conclusion: The resulting 44-item Suicide Stigma Assessment Scale (SSAS) can be further validated and used to measure efficacy of stigma change interventions.

Do Undiagnosed Suicide Decedents Have Symptoms of a Mental Disorder?

BACKGROUND

Psychological autopsy studies consistently report that the rate of detected mental disorders among suicide decedents is below 100%. This implies three possibilities: (a) a subset of suicide decedents did not have a mental disorder at the time of death; (b) all suicide decedents suffered from a mental disorder, but some were undetected due to methodological limitations; and/or (c) suicide decedents with an undetected mental disorder displayed significant and perhaps subclinical features of a mental disorder.

OBJECTIVE

In this article, we examined these possibilities by evaluating the differences in symptoms and stressors between suicide decedents who were undiagnosed and those diagnosed with a mental disorder at the time of death.

METHOD

We reviewed 130 case studies of community-based suicide decedents originally described in Robins' (1981) psychological autopsy study.

RESULTS

Without exception, suicide decedents in Robins' sample suffered either from a clearly diagnosable mental disorder or displayed features indicative of a significant, even if subclinical, presentation of a mental disorder. Undiagnosed and diagnosed suicide decedents did not significantly differ with regards to demographics, violence of suicide method, suicide attempt history, the number and intensity of stressful life events preceding death, and whether their death was a murder-suicide.

CONCLUSION

Although clearly not all who suffer from mental disorders will die by suicide, these findings imply that all who die by suicide appear to exhibit, at minimum, subclinical psychiatric symptoms with the great majority showing prominent clinical symptoms. We conclude with clinical implications and recommendations for future study.

Caught between intending and doing: older people ideating on a self-chosen death

OBJECTIVES

The aim of this paper is to provide insight into what it means to live with the intention to end life at a self-chosen moment from an insider perspective.

SETTING

Participants who lived independent or semidependent throughout the Netherlands.

PARTICIPANTS

25 Dutch older citizens (mean age of 82 years) participated. They were ideating on a self-chosen death because they considered their lives to be no longer worth living. Inclusion criteria were that they: (1) considered their lives to be 'completed'; (2) suffered from the prospect of living on; (3) currently wished to die; (4) were 70 years of age or older; (5) were not terminally ill; (6) considered themselves to be mentally competent; (7) considered their death wish reasonable.

DESIGN

In this qualitative study, in-depth interviews were carried out in the participants' everyday home environment (median lasting 1.56 h). Verbatim transcripts were analysed based on the principles of phenomenological thematic analysis.

RESULTS

The liminality or 'in-betweenness' of intending and actually performing self-directed death (or not) is characterised as a constant feeling of being torn explicated by the following pairs of themes: (1) detachment and attachment; (2) rational and non-rational considerations; (3) taking control and lingering uncertainty; (4) resisting interference and longing for support; (5) legitimacy and illegitimacy.

CONCLUSIONS

Our findings show that the in-between period emerges as a considerable, existential challenge with both rational and non-rational concerns and thoughts, rather than a calculative, coherent sum of rational considerations. Our study highlights the need to take due consideration of all ambiguities and ambivalences present after a putatively rational decision has been made in order to develop careful policy and support for this particular group of older people.

The Supreme Court of Canada Ruling on Physician-Assisted Death: Implications for Psychiatry in Canada

On February 6, 2015, the Supreme Court of Canada ruled that the prohibition of physician-assisted death (PAD) was unconstitutional for a competent adult person who "clearly consents to the termination of life" and has a "grievous and irremediable (including an illness, disease, or disability) condition that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition." The radically subjective nature of this ruling raises important questions about who will be involved and how this practice might be regulated. This paper aims to stimulate discussion about psychiatry's role in this heretofore illegal practice and to explore how psychiatry might become involved in end-of-life care in a meaningful, patient-centred way. First, I will review existing international legislation and professional regulatory standards regarding psychiatry and PAD. Second, I will discuss important challenges psychiatry might face regarding capacity assessment, the notion of rational suicide, and the assessment of suffering.

Culturally sanctioned suicide: Euthanasia, seppuku, and terrorist martyrdom

Suicide is one of the greatest concerns in psychiatric practice, with considerable efforts devoted to prevention. The psychiatric view of suicide tends to equate it with depression or other forms of mental illness. However, some forms of suicide occur independently of mental illness and within a framework of cultural sanctioning such that they aren’t regarded as suicide at all. Despite persistent taboos against suicide, euthanasia and physician-assisted suicide in the context of terminal illness is increasingly accepted as a way to preserve autonomy and dignity in the West. Seppuku, the ancient samurai ritual of suicide by self-stabbing, was long considered an honorable act of self-resolve such that despite the removal of cultural sanctioning, the rate of suicide in Japan remains high with suicide masquerading as seppuku still carried out both there and abroad. Suicide as an act of murder and terrorism is a practice currently popular with Islamic militants who regard it as martyrdom in the context of war. The absence of mental illness and the presence of cultural sanctioning do not mean that suicide should not be prevented. Culturally sanctioned suicide must be understood in terms of the specific motivations that underlie the choice of death over life. Efforts to prevent culturally sanctioned suicide must focus on alternatives to achieve similar ends and must ultimately be implemented within cultures to remove the sanctioning of self-destructive acts.

Last wills and testaments in a large sample of suicide notes: implications for testamentary capacity

BACKGROUND

The leaving of a will prior to death by suicide is a relatively unexplored area.

AIMS

To determine the frequency and details of will content in suicide notes.

METHOD

Coroner records for 1565 deaths by suicide in Toronto (2003-2009) were reviewed for (a) will content and (b) the presence of depression, psychotic illness, dementia and intoxication prior to death.

RESULTS

In total, 59 (20.7%) of 285 available suicide notes were found to have will content. Of those who left a will, 43 (72.9%) were reported to have a major mood or psychotic disorder, but none had dementia. Fifteen of 19 toxicology samples showed alcohol, sedative hypnotic/benzodiazepine, opioid and/or recreational drugs were present.

CONCLUSIONS

A substantial minority of suicide notes may also include testamentary intent. The observed high rate of mental illness and substance use around the time of death has important clinical implications for understanding the mindset of people who die by suicide and hence also legal implications regarding testamentary capacity.

The right to life in a suicidal state

This paper considers when the State must take positive steps to protect the right to life of a suicidal patient. Using recent developments across the Council of Europe which challenge the traditional 'ugly Samaritan' approach of many common law systems, it contends that whenever and wherever public authorities know or ought to know of a real and immediate risk to the life of an identifiable person, they must take reasonable precautions to minimise it. Even J. S. Mill's approach to liberty, it is suggested, would tolerate this limited degree of State interference. However, notions of autonomy and dignity, the unpredictability of human behaviour, and the need to avoid unduly burdening the State must influence what it means to act reasonably.