Legal provisions on medical aid in dying encode moral intuition

In recent decades, many jurisdictions have moved toward legalizing euthanasia and assisted suicide, alongside a near-universal increase in public acceptance of medical aid in dying. Here, we draw on a comprehensive quantitative review of current laws on assisted dying, experimental survey evidence, and four decades of time-series data to explore the relationship between these legislative transitions and change in moral attitudes. Our analyses reveal that existing laws on medical aid in dying impose a common set of eligibility restrictions, based on the patient's age, decision-making capacity, prognosis, and the nature of their illness. Fulfillment of these eligibility criteria elevates public moral approval of physician-assisted death, equally in countries with (i.e., Spain) and without (i.e., the United Kingdom) assisted dying laws. Finally, historical records of public attitudes toward euthanasia across numerous countries uncovered anticipatory growth in moral approval leading up to legalization, but no accelerated growth thereafter. Taken together, our findings suggest that the enactment of medical aid in dying laws, and their specific provisions, crystallize patterns in moral intuition.

Microglial Dysregulation and Suicidality: A Stress-Diathesis Perspective

According to the stress-diathesis model of suicidal behavior, completed suicide depends on the interaction between psychosocial stressors and a trait-like susceptibility. While there are likely multiple biological processes at play in suicidal behavior, recent findings point to over-activation of microglia, the resident macrophages of the central nervous system, as implicated in stress-induced suicidal behavior. However, it remains unclear how microglial dysregulation can be integrated into a clinical model of suicidal behavior. Therefore, this narrative review aims to (1) examine the findings from human post-mortem and neuroimaging studies that report a relationship between microglial activation and suicidal behavior, and (2) update the clinical model of suicidal behavior to integrate the role of microglia. A systematic search of SCOPUS, PubMed, PsycINFO, and Embase databases revealed evidence of morphological alterations in microglia and increased translocator protein density in the brains of individuals with suicidality, pointing to a positive relationship between microglial dysregulation and suicidal behavior. The studies also suggested several pathological mechanisms leading to suicidal behavior that may involve microglial dysregulation, namely (1) enhanced metabolism of tryptophan to quinolinic acid through the kynurenine pathway and associated serotonin depletion; (2) increased quinolinic acid leading to excessive N-methyl-D-aspartate-signaling, resulting in potential disruption of the blood brain barrier; (3) increased quinolinic acid resulting in higher neurotoxicity, and; (4) elevated interleukin 6 contributing to loss of inhibition of glutamatergic neurons, causing heightened glutamate release and excitotoxicity. Based on these pathways, we reconceptualized the stress-diathesis theory of suicidal behavior to incorporate the role of microglial activity.

The disease burden of suicide in Ecuador, a 15 years' geodemographic cross-sectional study (2001-2015)

BACKGROUND

Suicide affects people from different backgrounds, ethnical groups, socio-economic status and geographical locations. In Latin America, suicide reports arescarce, specially in Andean countries. In Ecuador, very few reports have partially described this phenomenon, nonetheless, estimation of the burden of disease (BoD) hasnever been reported in the country.

METHODS

A country-wide comparison was performed using the Ministry of Public Health's national databases of overall mortality, Hospital Discharges Database, and the Population Census of the National Institute of Census and Statistics (INEC). The study variables analyzed were age, geographical distribution to provincial level, sex, means of suicide, educational attainment, marital status and mortality. Linear Regression and relative Risk analysis were used to predict outcome and the likelihood that suicide occur among study variables.

RESULTS

In the last 15 years, 13,024 suicides were officially reported. Men were 3 times more likely than women to die by suicide. The overall age-adjusted suicide ratio in Ecuador corresponds to 7.1 per 100,000 per year. The sex-specific rates were 5.3 in women and 13.2 in men. The primary mean of suicide was hanging X70 (51.1%), followed by self-poisoning X68-X69 (35.2%) and firearms X72-X74 (7.6%). Provinces located at higher altitude reported higher rates than those located at sea level (9 per 100,000 vs 4.5 per 100.000). The total economic loss due to suicide was estimated to be $852.6 million during the 15 years' analysis.

CONCLUSIONS

This is the first geodemographic study exploring the complete burden of suicide in Ecuador and one of the very few in Latin-America. In the last 15 years of available data, Ecuador ranks above the regional average with an adjusted suicide rate of 7.1 per 100,000 inhabitants. An important finding is that Suicide affects rather younger populations, adding more than 10,000 years of premature years of life lost (YYL) between 2001 and 2015, becoming the first and fourth leading cause of death among adolescent women and men respectively. Suicide affects people from different backgrounds, socioeconomic status and educational attainment. The mean of suicide changed over time showing that gun and pesticides related deaths decreased significantly since 2001, while hanging and suffocation increased in more than 50%.

Depression as an evolutionary strategy for defense against infection

Recent discoveries relating depression to inflammation and immune function may help to solve an important evolutionary puzzle: If depression carries with it so many negative consequences, including notable costs to survival and reproduction, then why is it common and heritable? What countervailing force or compensatory advantage has allowed susceptibility genes for depression to persist in the population at such high rates? A priori, compensatory advantages in combating infection are a promising candidate, given that infection has been the major cause of mortality throughout human history. Emerging evidence on deeply rooted bidirectional pathways of communication between the nervous and immune systems further supports this notion. Here we present an updated review of the "infection-defense hypothesis" of depression, which proposes that moods-with their ability to orchestrate a wide array of physical and behavioral responses-have played an adaptive role throughout human history by helping individuals fight existing infections, as well as helping both individuals and their kin avoid new ones. We discuss new evidence that supports several key predictions derived from the hypothesis, and compare it with other major evolutionary theories of depression. Specifically, we discuss how the infection-defense hypothesis helps to explain emerging data on psychoimmunological features of depression, as well as depression's associations with a diverse array of conditions and illnesses-including nutritional deficiencies, seasonal changes, hormonal fluctuations, and chronic diseases-that previous evolutionary theories of depression have not accounted for. Finally, we note the potential implications of the hypothesis for the treatment and prevention of depression.

Animal model and neurobiology of suicide

Animal models are formidable tools to investigate the etiology, the course and the potential treatment of an illness. No convincing animal model of suicide has been produced to date, and despite the intensive study of thousands of animal species naturalists have not identified suicide in nonhuman species in field situations. When modeling suicidal behavior in the animal, the greatest challenge is reproducing the role of will and intention in suicide mechanics. To overcome this limitation, current investigations on animals focus on every single step leading to suicide in humans. The most promising endophenotypes worth investigating in animals are the cortisol social-stress response and the aggression/impulsivity trait, involving the serotonergic system. Astroglia, neurotrophic factors and neurotrophins are implied in suicide, too. The prevention of suicide rests on the identification and treatment of every element increasing the risk.

An Evolutionary Hypothesis of Suicide: Why it Could be Biologically Adaptive and is so Prevalent in Certain Occupations

From an evolutionary perspective, suicide is a puzzle, because it has serious adverse effects, yet is remarkably common and heritable. An hypothesis is proposed to explain this puzzle, by explaining how suicide could be adaptive through reducing risk that individuals will transmit infections to kin. Empirical evidence supports four predictions from the hypothesis. There are well-established mechanisms by which infections and immune factors increase risk for mental disorders that contribute to suicide. Suicide is more prevalent in occupations with greater exposure to infection and immune-compromising factors and at higher latitudes, where key environmental factors increase vulnerability to infection. In several other highly social species, suicide-like behaviors have evolved to reduce transmission of infections. If the hypothesis is correct, detection and treatment of underlying infections and immune dysfunction should help predict and prevent suicidal behavior, while also combating spread of infectious diseases.