Curable Depression or Understandable Misery in Requests for Medically-Assisted Rational Suicide?

One of the concerns over legalized medically assisted rational suicide (MARS), is the risk that someone requesting it may be suffering from a treatable depression.  Is it possible to tell the difference between someone rationally requesting assisted suicide when they feel their life is complete, and someone so irrationally depressed that they feel suicidal and really need treatment? To attempt to answer this, we first need to look at what is meant by “depression” and related psychiatric conditions that carry a significant risk of suicide.

The term ‘depression’ only became widely used after the 19th century. By the 1960s, it was commonly divided between ‘endogenous’ and ‘reactive’ types. The former had no obvious or sufficient underlying causes such as work, marital or personality problems and physical illness, and was seen as probably reflecting some as yet undiscovered biochemical upset in the brain. That is probably true but despite much research involving the latest scanners and lots of pretty coloured pictures of the brain, we still lack really convincing biochemical explanations.

Research (much of it British) showed that other than the lack of obvious precipitating factors, there was often no major difference between ‘endogenous’ and ‘reactive’ symptoms. That should surprise nobody who has seen someone absolutely devastated by the loss of a partner, a child, a future, or a reputation. The majority of suicides are the result of such personal catastrophes. They may be more likely to occur in people who are less resilient to such difficulties than the large majority who don’t respond by seeking to end their lives. There is no prima facie reason why we should regard that vulnerability as having mainly biological rather than mainly personal or psychological explanations. If there are biological factors, we have no drugs that diminish them.

Psychiatric definitions of ‘depression’ have concentrated increasingly on the symptoms of depression while largely ignoring possible or even obvious precipitating causes. However, there has been argument in the field over whether at least some kinds of ‘depression’ should be regarded not as diseases meriting pharmacological and/or psychological treatment but as an understandable and entirely logical reaction to unhappy events. Bereavement has been a case in point.

This might not matter too much if antidepressants had large and specific cheering-up effects for the majority of people with depression, but they don’t. If they did, we might expect to have seen significant falls in the number of suicides, like the falls in other life-endangering conditions when effective treatments appeared. There is little evidence that the large and fairly steady increase in antidepressant prescribing has had any obvious effect on reducing suicides. There was a temporary fall in the suicide rate in the 1960s, but this can be explained by the introduction of North Sea gas which rendered the gas oven useless as a suicide method. Previously it had been a favoured method. At the milder end of the depression severity spectrum, antidepressants have also had no obvious effect, for in spite of the growth of antidepressant prescribing and of counselling and psychotherapy, ‘depression’, together with ‘stress’ and ‘anxiety’ (for which antidepressants are often prescribed anyway) is now the third largest reason for being off work and receiving sickness benefits. ‘Serious mental health problems’ (mostly manic-depressive illness and schizophrenia) account for barely a twentieth as much sickness benefit.

Manic-depressive illness, now often called ‘bipolar disorder’ is a more obviously ‘biochemical’ mental disorder, at least in its severer forms. Being uncharacteristically depressed for weeks or months in response to major misfortune is common and understandable but being uncharacteristically overactive, euphoric, loud, jocular and spendthrift for weeks at a time and often in the middle of the night as well is neither. The classic pattern is episodes of depression or mania lasting for weeks or months with variable but often lengthy periods of normality in between. Some have mainly depressive episodes; others mainly manic.

Many people improve – somewhat or considerably – after receiving antidepressants but almost as many improve after receiving placebo tablets and there are several controlled trials comparing antidepressants with placebos that show no advantage for the real tablet compared with the dummy one. Overall, however, trials mostly show that between one half and two-thirds respond well to the dummy, another 10-20% at most may respond to the antidepressant and the rest don’t respond much or at all. A recent World Psychiatric Association review questioned even that 10-20%. Unsurprisingly, trials funded by drug companies consistently get more positive results than those done by independent and traditionally sceptical academics.

Suicidal feelings are common in both understandable and non-understandable unhappiness. Some sufferers may be helped by antidepressants, but for others, time and a little help from one’s friends often sees them disappear. These comparatively short-lived suicidal feelings, from which recovery is usual, are very different from the desire to die expressed by many people experiencing subjectively intolerable distress due to terminal, progressive or stable but intractable diseases or conditions. People with ‘ordinary’ suicidal feelings, resulting from some form of ‘depression’, and who are in contact with doctors usually ask for help to make those feelings go away. That help may be social (e.g. better housing, getting employment), pharmacological, various sorts of psychotherapy, or all three.

In very sharp contrast, the sort of people who contemplate or request Medically Assisted Rational Suicide (MARS) do not want any of these interventions. Unlike the ‘ordinary’ patients, whose suicidal feelings are often short-lived or even impulsive, they have thought long and carefully about their situation. In nearly all cases of terminal or progressive illness, they first thought about what they might do in this situation long before the disease first appeared. Ordinary depressed patients tend not to be cheerful or jocular but most people who request MARS would prefer to live if their afflictions could be cured or greatly relieved and their sense of humour is usually well-preserved. They are often quite cheerful, which is surely a perfectly rational response to the knowledge that they can save themselves – and usually their nearest and dearest as well – a great deal of personal and vicarious suffering that would otherwise be inevitable. Unlike ordinary depressives, they often eat and sleep well if their disease allows it and they continue to take pleasure in their usual hobbies and relationships. On the standard depression questionnaires, they usually score well below the cut-off point for a diagnosis. It is therefore not usually difficult for a suitably trained doctor to distinguish people suffering from depression with a reasonable chance of recovery from those seeking MARS.

Because both unhappiness and antidepressant prescribing are common in our society and because most people requesting MARS are over 60, it sometimes happens that such people have, in previous years, been given a diagnosis of ‘depression’ and have sometimes received antidepressants as well. The Swiss MARS-providers, such as DIGNITAS and Lifecircle, are always punctilious about requiring a psychiatric assessment in such cases, even if the antidepressant was prescribed not for depression but for pain relief, where they are sometimes modestly useful in patients who are not clinically depressed.

In any case, doctors involved with patients contemplating MARS should routinely look for any signs that the request is the result of a recent and atypical change of mood and not the obvious outcome of a gradual conclusion that their life is complete, coupled with a long held belief that assisted suicide would be their idea of a ‘good death’.

While most requests for MARS reflect underlying physical conditions and are not due to psychiatric disorders, a very small proportion of requests in Holland and Belgium are made because of severe and chronic psychiatric illnesses that have not responded to many years of appropriate treatment and have left the patients consistently longing for death. In most cases, they have already made several serious suicide attempts. Symptoms were usually present from childhood or early adolescence and did not improve with age and experience. Diagnoses typically included a personality disorder as well as intractable depression or obsessive-compulsive problems. Barely half of all such requests are granted but as with MARS for physical conditions, knowing that the option is available enables some patients to keep going. In deciding when MARS may be appropriate in psychiatric cases it is important to take into account that incurable psychiatric illness can cause patients and their families even more distress than the worst phases of cancer and for much longer. The Dutch film-maker Elena Lindemans recently made a documentary called ‘Mothers don’t jump off buildings’. It was about her own mother, who did exactly that after her repeated pleas for MARS had been rejected. Lindemans made the film  after she had tried for ten years to repress her very traumatic memories of the event and get on with her life. In Holland and Belgium patients can talk meaningfully about their wish for death with experienced clinicians, in the knowledge that MARS is a possible outcome. Another moving video, created by the Economist, shows how these extremely challenging and tragic cases are handled with great sensitivity and professionalism in Belgium.

Dr Colin Brewer
Retired psychiatrist and MDMD Associate Coordinator

An excellent discussion of the arguments for and against Assisted Dying in cases of purely psychiatric illness is presented in an article by Ryan Tanner, a member of the Canadian Joint Centre for Bioethics Task Force on Medical Assistance in Dying: Mental Illness and Access to Assisted Dying, February 15, 2017