Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors

BACKGROUND: A bill to legalize physician-assisted suicide in the UK recently made significant progress in the British House of Lords and will be reintroduced in the future. Until now there has been little discussion of the clinical implications of physician-assisted suicide for the UK. This paper describes problematical issues that became apparent from a review of the medical and psychiatric literature as to the potential effects of legalized physician-assisted suicide. DISCUSSION: Most deaths by physician-assisted suicide are likely to occur for the illness of cancer and in the elderly. GPs will deal with most requests for assisted suicide. The UK is likely to have proportionately more PAS deaths than Oregon due to the bill's wider application to individuals with more severe physical disabilities. Evidence from other countries has shown that coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide. Depression influences requests for hastened death in terminally ill patients, but is often under-recognized or dismissed by doctors, some of whom proceed with assisted death anyway. Psychiatric evaluations, though helpful, do not solve these problems. Safeguards that are incorporated into physician-assisted suicide criteria probably decrease but do not prevent its misapplication. SUMMARY: The UK is likely to face significant clinical problems arising from physician-assisted suicide if it is legalized. Terminally ill patients with mental illness, especially depression, are particularly vulnerable to the misapplication of physician-assisted suicide despite guidelines and safeguards

Narcissism in patients admitted to psychiatric acute wards: its relation to violence, suicidality and other psychopathology

<p>Abstract</p> <p>Background</p> <p>The objective was to examine various aspects of narcissism in patients admitted to acute psychiatric wards and to compare their level of narcissism to that of an age- and gender-matched sample from the general population (NORM).</p> <p>Methods</p> <p>This cross-sectional study interviewed 186 eligible acute psychiatric patients with the Brief Psychiatric Rating Scale (BPRS) and the Global Assessment of Functioning (GAF). The patients filled in the Narcissistic Personality Inventory-21 item version (NPI-21), The Hospital Anxiety and Depression Scale (HADS) and the Rosenberg Self-Esteem Scale. High and low narcissism was defined by the median of the total NPI-21 score. An age- and gender-matched control sample from the general population also scored the NPI-21 (NORM).</p> <p>Results</p> <p>Being male, involuntary admitted, having diagnosis of schizophrenia, higher self-esteem, and severe violence were significantly associated with high narcissism, and so were also low levels of suicidality, depression, anxiety and GAF scores. Severe violence and high self-esteem were significantly associated with high narcissism in multivariable analyses. The NPI-21 and its subscales showed test-retest correlations ≥0.83, while the BPRS and the HADS showed lower correlations, confirming the trait character of the NPI-21. Depression and suicidality were negatively associated with the NPI-21 total score and all its subscales, while positive association was observed with grandiosity. No significant differences were observed between patients and NORM on the NPI-21 total score or any of the NPI subscales.</p> <p>Conclusion</p> <p>Narcissism in the psychiatric patients was significantly associated with violence, suicidality and other symptoms relevant for management and treatment planning. Due to its trait character, use of the NPI-21 in acute psychiatric patients can give important clinical information. The similar level of narcissism found in patients and NORM is in need of further examination.</p

Psychodynamic Experience Enhances Recognition of Hidden Childhood Trauma

BACKGROUND: Experimental psychology has only recently provided supporting evidence for Freud's and Janet's description of unconscious phenomena. Here, we aimed to assess whether specific abilities, such as personal psychodynamic experience, enhance the ability to recognize unconscious phenomena in peers - in other words, to better detect implicit knowledge related to individual self-experience. METHODOLOGY AND PRINCIPAL FINDINGS: First, we collected 14 videos from seven healthy adults who had experienced a sibling's cancer during childhood and seven matched controls. Subjects and controls were asked to give a 5-minute spontaneous free-associating speech following specific instructions created in order to activate a buffer zone between fantasy and reality. Then, 18 raters (three psychoanalysts, six medical students, three oncologists, three cognitive behavioral therapists and three individuals with the same experience of trauma) were randomly shown the videos and asked to blindly classify them according to whether the speaker had a sibling with cancer using a Likert scale. Using a permutation test, we found a significant association between group and recognition score (ANOVA: p = .0006). Psychoanalysts were able to recognize, above chance levels, healthy adults who had experienced sibling cancer during childhood without explicit knowledge of this history (Power = 88%; p = .002). In contrast, medical students, oncologists, cognitive behavioral therapists and individuals who had the same history of a sibling's cancer were unable to do so. CONCLUSION: This experiment supports the view that implicit recognition of a subject's history depends on the rater's specific abilities. In the case of subjects who did have a sibling with cancer during childhood, psychoanalysts appear better able to recognize this particular history

Deep brain stimulation for obsessive-compulsive disorder and treatment-resistant depression: systematic review

<p>Abstract</p> <p>Background</p> <p>In spite of advances in psychotherapy and pharmacotherapy, there are still a significant number of patients with depression and obsessive-compulsive disorder that are not aided by either intervention. Although still in the experimental stage, deep brain stimulation (DBS) offers many advantages over other physically-invasive procedures as a treatment for these psychiatric disorders. The purpose of this study is to systematically review reports on clinical trials of DBS for obsessive-compulsive disorder (OCD) and treatment-resistant depression (TRD). Locations for stimulation, success rates and effects of the stimulation on brain metabolism are noted when available. The first observation of the effects of DBS on OCD and TRD came in the course of using DBS to treat movement disorders. Reports of changes in OCD and depression during such studies are reviewed with particular attention to electrode locations and associated adverse events; although these reports were adventitious observations rather than planned. Subsequent studies have been guided by more precise theories of structures involved in DBS and OICD. This study suggests stimulation sites and prognostic indicators for DBS. We also briefly review tractography, a relatively new procedure that holds great promise for the further development of DBS.</p> <p>Methods</p> <p>Articles were retrieved from MEDLINE via PubMed. Relevant references in retrieved articles were followed up. We included all articles reporting on studies of patients selected for having OCD or TRD. Adequacy of the selected studies was evaluated by the Jadad scale. Evaluation criteria included: number of patients, use of recognized psychiatric rating scales, and use of brain blood flow measurements. Success rates classified as "improved" or "recovered" were recorded. Studies of DBS for movement disorders were included if they reported coincidental relief of depression or reduction in OCD. Most of the studies involved small numbers of subjects so individual studies were reviewed.</p> <p>Results</p> <p>While the number of cases was small, these were extremely treatment-resistant patients. While not everyone responded, about half the patients did show dramatic improvement. Associated adverse events were generally trivial in younger psychiatric patients but often severe in older movement disorder patients. The procedures differed from study to study, and the numbers of patients was usually too small to do meaningful statistics or make valid inferences as to who will respond to treatment.</p> <p>Conclusions</p> <p>DBS is considered a promising technique for OCD and TRD. Outstanding questions about patient selection and electrode placement can probably be resolved by (a) larger studies, (b) genetic studies and (c) imaging studies (MRI, fMRI, PET, and tractography).</p

Psychodynamic Experience Enhances Recognition of Hidden Childhood Trauma

BACKGROUND: Experimental psychology has only recently provided supporting evidence for Freud's and Janet's description of unconscious phenomena. Here, we aimed to assess whether specific abilities, such as personal psychodynamic experience, enhance the ability to recognize unconscious phenomena in peers - in other words, to better detect implicit knowledge related to individual self-experience. METHODOLOGY AND PRINCIPAL FINDINGS: First, we collected 14 videos from seven healthy adults who had experienced a sibling's cancer during childhood and seven matched controls. Subjects and controls were asked to give a 5-minute spontaneous free-associating speech following specific instructions created in order to activate a buffer zone between fantasy and reality. Then, 18 raters (three psychoanalysts, six medical students, three oncologists, three cognitive behavioral therapists and three individuals with the same experience of trauma) were randomly shown the videos and asked to blindly classify them according to whether the speaker had a sibling with cancer using a Likert scale. Using a permutation test, we found a significant association between group and recognition score (ANOVA: p = .0006). Psychoanalysts were able to recognize, above chance levels, healthy adults who had experienced sibling cancer during childhood without explicit knowledge of this history (Power = 88%; p = .002). In contrast, medical students, oncologists, cognitive behavioral therapists and individuals who had the same history of a sibling's cancer were unable to do so. CONCLUSION: This experiment supports the view that implicit recognition of a subject's history depends on the rater's specific abilities. In the case of subjects who did have a sibling with cancer during childhood, psychoanalysts appear better able to recognize this particular history

Making sense of the evolving nature of depression narratives and their inherent conflicts

Originally a psychiatric diagnosis fashioned by Western psychiatry in the 20th Century, depression evolved to encompass varying lineages of discourse and care. This article elucidates some of the current challenges – as well as emerging discourses – influencing the category of depression. Depression-like experiences are shaped by (at times conflicting) subjectivities, claims to knowledge, material realities, social contexts and access to resources. With no unified understanding of the category of ‘depression’ available, lay people, social and neuro scientists, GPs, psychiatrists, talking therapists and pharmaceutical companies all attempt to shape narratives of depression. The current paper focuses on patient narratives about depression – in the context of these wider debates – to better elucidate the ways in which depression discourses are publically developing along varying lines. In conclusion, the paper suggests that we could better conceptualise the resulting ‘depression(s)’ with concepts such as ‘society of mind’ and notions of subjectivity unbounded by individuals

Prediction and prevention of suicide in patients with unipolar depression and anxiety

Epidemiological data suggest that between 59 and 87% of suicide victims suffered from major depression while up to 15% of these patients will eventually commit suicide. Male gender, previous suicide attempt(s), comorbid mental disorders, adverse life-situations, acute psycho-social stressors etc. also constitute robust risk factors. Anxiety and minor depression present with a low to moderate increase in suicide risk but anxiety-depression comorbidity increases this risk dramatically Contrary to the traditional psychoanalytic approach which considers suicide as a retrospective murder or an aggression turned in-wards, more recent studies suggest that the motivations to commit suicide may vary and are often too obscure. Neurobiological data suggest that low brain serotonin activity might play a key role along with the tryptophan hydroxylase gene. Social factors include social support networks, religion etc. It is proven that most suicide victims had asked for professional help just before committing suicide, however they were either not diagnosed (particularly males) or the treatment they received was inappropriate or inadequate. The conclusion is that promoting suicide prevention requires the improving of training and skills of both psychiatrists and many non-psychiatrists and especially GPs in recognizing and treating depression and anxiety. A shift of focus of attention is required in primary care to detect potentially suicidal patients presenting with psychological problems. The proper use of antidepressants, after a careful diagnostic evaluation, is important and recent studies suggest that successful acute and long-term antidepressant pharmacotherapy reduces suicide morbidity and mortality