October 9, 2008 — New research is raising concerns that assisted-suicide laws may not adequately protect terminally ill individuals who have comorbid clinical depression.
A cross-sectional study by researchers from Oregon Health and Science University, in Portland, reveals that some patients who opt for physician-assisted suicide in Oregon, the only US state where the practice is legal, are clinically depressed.
"On one hand, we found that among people who were able to access lethal prescriptions, 83% had no evidence of psychiatric or depressive disorder. But there were a small number of patients with significant depression who did get lethal prescriptions but who had not been assessed by a psychiatrist," principal investigator Linda Ganzini, MD, told Medscape Psychiatry.
The study is published online October 8 in BMJ.
Conflicting Findings
In 1994, the State of Oregon passed the Death with Dignity Act, legalizing physician-assisted dying for terminally ill patients. The law authorizes a physician to prescribe a lethal dose of a drug, usually a short-acting barbiturate, to a competent individual who requests such assistance and self-administers the medication.
The law also requires psychiatric referral in cases where the primary-care physician suspects a psychiatric disorder, such as depression, that could potentially impair a terminally ill patient's judgment.
However, said Dr. Ganzini, the extent to which clinical depression impairs judgment in the terminally ill is not clear and has been the subject of considerable debate over the years.
Interviews and surveys of terminally ill patients' healthcare providers and family members indicate depression does not play a substantial role in a patient's decision to seek aid in dying. However, said Dr. Ganzini, this research runs contrary to studies in terminally ill cancer patients who have attempted or completed suicide that reveal very high rates of mental disorders, including depression, of up to 80%.
The current study, she said, was an attempt to reconcile these disparate findings.
Call for More Vigilant Depression Screening
To determine the prevalence of depression and anxiety in terminally ill patients, the investigators conducted a cross-sectional survey of 58 terminally ill Oregonians who had formally requested aid in dying.
The study's main outcome was a diagnosis of depression or anxiety. Standardized measures, including the standardized interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV), were used to assess depression and anxiety.
Of the total study group, 1 in 4 (15) met the criteria for clinical depression. In addition, 13 met the criteria for anxiety. A total of 42 patients died by the end of the study. Of these, 18 received a prescription for a lethal medication and 9 died by lethal ingestion.
Of the 18 patients who received a lethal prescription, 15 did not meet the criteria for depression, but 3 did, and all 3 died by lethal ingestion within 2 months of the research interview.
According to Dr. Ganzini, research shows that treating depression in suicidal patients is effective in reducing suicidal ideation. In addition, she said, research shows that treating depression in terminally ill patients increases interest in life-sustaining medical treatment.
She added that the results point to a need for increased vigilance and a more systematic approach to depression screening in patients with terminal illness.
Does Depression Impair Judgment?
In an accompanying editorial, Marije van der Lee, MD, from the Helen Dowling Institute, in Utrecht, Netherlands says that while it is vital to protect vulnerable patients, examining terminally ill patients to determine whether depression is impairing their judgment is complex.
She believes that depression does not necessarily impair judgment and points out that in the Netherlands, where assisted suicide is also legal, the most important consideration is that the patient makes an informed decision.
"In my opinion, screening for depression must take place at an earlier stage, when active treatment to prolong life stops and the phase of symptom palliation begins. Given that a quarter of terminally ill patients with cancer have depressive disorders, screening all terminally ill patients systematically seems advisable, rather than screening only the minority of patients seeking legalized assistance in dying," Dr. van der Lee writes.
The authors disclose no relevant conflicts of interest.
BMJ. Published online October 8, 2008.
Medscape Medical News © 2008 Medscape
Cite this: Caroline Cassels. Assisted-Suicide Law May Not Adequately Protect Depressed Patients - Medscape - Oct 09, 2008.
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