A review of euthanasia or assisted suicide (EAS) cases among patients with psychiatric disorders in the Netherlands found that most had chronic, severe conditions, with histories of attempted suicides and hospitalizations, and were described as socially isolated or lonely, according to an article published online by JAMA Psychiatry. 
 
 The practice of EAS has been around for decades in the Netherlands, although formal legislation was not unacted until 2002. Scott Y.H. Kim, M.D., Ph.D., of the National Institutes of Health, Bethesda, Md., and coauthors describe the characteristics of patients receiving EAS for psychiatric conditions and how the practice is regulated in the Netherlands. Summaries of cases of EAS for psychiatric conditions were made available online by Dutch regional euthanasia review committees. The study authors reviewed 66 cases for 2011 to 2014. 
 
 Of the 66 cases, 46 of them were women (70 percent); 32 percent of patients (n=21) were 70 or older; 44 percent (n=29) were 50 to 70 years old; and 24 percent (n=16) were 30 to 50 years old. Among the patients, 52 percent (n=34) had attempted suicide and 80 percent (n=53) had been hospitalized for psychiatric reasons. 
 
 Most patients had more than one psychiatric condition and depressive disorders were the primary psychiatric issue in 55 percent (n=36) of cases. Some patients had undergone electroconvulsive therapy for difficult-to-treat depression. However, in the case of one woman in her 70s with no health problems, she and her husband had decided years earlier that they would not live without each other. After he died, she described her life as a "living hell" and "meaningless," although the women reportedly "did not feel depressed at all" and ate, drank, and slept well, according to the study. 
 
 About 52 percent (34 of 66) of patients had personality-related problems, although sometimes without a formal diagnosis and more than a majority of patients had at least one coexisting illness, including cancer, cardiac disease, diabetes, stroke and others. 
 
 Reports on 37 patients (56 percent) mentioned social isolation and loneliness, including one patient who "indicated that she had a life without love and therefore had no right to exist" and another described as "an utterly lonely man whose life had been a failure." 
 
 Some of the patients had a history of EAS refusal. Among them, 21 patients (32 percent) had been refused EAS at some point but physicians later changed their mind about three of them and performed EAS, while the remaining 18 patients had physicians who were new to them perform the EAS. In 14 cases, the new physician was affiliated with a mobile euthanasia practice End-of-Life Clinic. 
 
 In 27 cases (41 percent), the physician performing EAS was a psychiatrist but in the rest of the cases it was usually general practitioners. Consultation with other physicians was extensive but in 11 percent (n=7) of cases there was no independent psychiatric input and 24 percent (n=16) of cases involved disagreements among physicians. Euthanasia review committees found only one case failed to meet the criteria for legal due care among all 110 reported psychiatric EAS cases during 2011 to 2014, the study reports. 
 
 "The retrospective oversight system in the Netherlands generally defers to the judgments of the physicians who perform and report EAS. Whether the system provides sufficient regulatory oversight remains an open question that will require further study," the study concludes. 
 
 (JAMA Psychiatry. Published online February 10, 2016. doi:10.1001/jamapsychiatry.2015.2887. Available pre-embargo to the media at http://media. jamanetwork. com .) 
 
 Editor's Note: The research costs of this study were supplied by the Intramural research Program, Department of Bioethics, National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. 
 
 Editorial: Physician-Assisted Deaths for Patients with Mental Disorders 
 
 "Although the data by Kim and colleagues can serve as indicators of problems with the Dutch system, it would be good to keep their data limitations in mind. Based as they are on reports filed by the physicians most directly involved in these cases, the accuracy of the information reported is unknown. For many variables, data had to be abstracted from narrative summaries translated from another language. The available sample did not reflect all cases involving psychiatric disorders. It is unclear why some reports were either not filed or not made publicly available or how the data might have differed if they were. Finally, because these cases are exclusively drawn from instances in which assisted death took place, we cannot conclude anything about the effectiveness of the screening process in excluding inappropriate cases. At the least, however, these data suggest the desirability of a more thorough examination of the Dutch process where patients with psychiatric disorders are concerned," writes Paul S. Applebaum, M.D., of the New York State Psychiatric Institute, New York. 
 
 (JAMA Psychiatry. Published online February 10, 2016. doi:10.1001/jamapsychiatry.2015.2890. Available pre-embargo to the media at http://media. jamanetwork. com .) 
 
 Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. 
 
 ### 
 
 To contact study corresponding author Scott Y.H. Kim, M.D., Ph.D., call Molly Freimuth at 301-594-5789 or email molly.freimuth@nih.gov. To contact editorial author Paul S. Applebaum, M.D., call Rachel Yarmolinsky at 646-774-5353 or email yarmoli@nyspi.columbia.edu. ||||| Importance Euthanasia or assisted suicide (EAS) of psychiatric patients is increasing in some jurisdictions such as Belgium and the Netherlands. However, little is known about the practice, and it remains controversial. 
 
 Objectives To describe the characteristics of patients receiving EAS for psychiatric conditions and how the practice is regulated in the Netherlands. 
 
 Design, Setting, and Participants This investigation reviewed psychiatric EAS case summaries made available online by the Dutch regional euthanasia review committees as of June 1, 2015. Two senior psychiatrists used directed content analysis to review and code the reports. In total, 66 cases from 2011 to 2014 were reviewed. 
 
 Main Outcomes and Measures Clinical and social characteristics of patients, physician review process of the patients’ requests, and the euthanasia review committees’ assessments of the physicians’ actions. 
 
 Results Of the 66 cases reviewed, 70% (n = 46) were women. In total, 32% (n = 21) were 70 years or older, 44% (n = 29) were 50 to 70 years old, and 24% (n = 16) were 30 to 50 years old. Most had chronic, severe conditions, with histories of attempted suicides and psychiatric hospitalizations. Most had personality disorders and were described as socially isolated or lonely. Depressive disorders were the primary psychiatric issue in 55% (n = 36) of cases. Other conditions represented were psychotic, posttraumatic stress or anxiety, somatoform, neurocognitive, and eating disorders, as well as prolonged grief and autism. Comorbidities with functional impairments were common. Forty-one percent (n = 27) of physicians performing EAS were psychiatrists. Twenty-seven percent (n = 18) of patients received the procedure from physicians new to them, 14 of whom were physicians from the End-of-Life Clinic, a mobile euthanasia clinic. Consultation with other physicians was extensive, but 11% (n = 7) of cases had no independent psychiatric input, and 24% (n = 16) of cases involved disagreement among consultants. The euthanasia review committees found that one case failed to meet legal due care criteria. 
 
 Conclusions and Relevance Persons receiving EAS for psychiatric disorders in the Netherlands are mostly women and of diverse ages, with complex and chronic psychiatric, medical, and psychosocial histories. The granting of their EAS requests appears to involve considerable physician judgment, usually involving multiple physicians who do not always agree (sometimes without independent psychiatric input), but the euthanasia review committees generally defer to the judgments of the physicians performing the EAS. ||||| Also Meets CME requirements for: 
 
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 Your quiz results: The filled radio buttons indicate your responses. The preferred responses are highlighted ||||| The study, led by Dr. Scott Y. H. Kim, a psychiatrist and bioethicist at the National Institutes of Health, looked at records of most of the cases of doctor-assisted death for psychiatric distress from 2011 to mid-2014. In 37 of those 66 cases, people had refused a recommended treatment that could have helped. The study did not evaluate cases of people who had been denied assistance. 
 
 Depression was the most common diagnosis, but loneliness was also a frequent theme. “The patient was an utterly lonely man whose life had been a failure,” read one account. In another, a woman in her 70s said she and her husband had decided years earlier that they would not live without each other. She had no health problems, but after her husband died, she described her life as “a living hell.” 
 
 Five states in this country have laws allowing doctors to prescribe life-ending drugs to mentally competent, terminally ill adults: Oregon, Vermont, Montana, Washington, and California. The California law is expected to take effect this year. By contrast, laws in several European countries allow such assistance for any competent person with “unbearable suffering” — regardless of the cause. 
 
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 Last year, a team of doctors in Belgium, where laws are similar to those in the Netherlands, reported that most people who sought doctor-assisted death for psychiatric problems had depression, personality disorders or both. The new study of the Netherlands fills out that picture considerably, detailing the agonizing decisions by both doctors and patients in cases that went forward, ending in voluntary death. 
 
 The researchers, who included Dr. John Peteet of Harvard Medical School and Raymond De Vries of the University of Michigan and Maastricht University in the Netherlands, found that 46 of the patients had been women, most 60 or older. 
 
 The depression was often mixed with other problems, like substance abuse, mild dementia or physical pain. More than half had received a diagnosis of a personality disorder, like avoidant or dependent personality, which are typically bound up with relationship problems. The group also included people with diagnoses of eating disorders and autism spectrum conditions. Many reported being intensely lonely. 
 
 “The Dutch system is really the idealized setting in which to try something like this,” said Dr. Kim, in an interview. “But still, you can see that there are many cases that make us question whether this is the right practice.” 
 
 In the Dutch system, consulting doctors review petitions for assistance in dying. In one quarter of the cases, the study found, the doctors disagreed. 
 
 Barbara Coombs Lee, president of Compassion and Choices, which advocates compassionate end-of-life care, said the debate over people with psychiatric conditions was not relevant to laws in the United States, which have been modeled on Oregon’s 1997 Death With Dignity Act. 
 
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 “I have seen no parallel movement or discussion at any level in this country,” Ms. Coombs Lee said. “I don’t know of anyone ever proposing this here, or of any poll supporting anything but self-administration by mentally competent, terminally ill adults.” ||||| By Andrew M. Seaman 
 
 (Reuters Health) - Laws permitting assisted suicide may justify the right of even psychiatric patients to end their lives in theory, but the reality of implementing such programs is messy, a study of the Netherlands finds. 
 
 Complex medical histories and disagreements among doctors were common elements among the Dutch cases of psychiatric patients who chose legalized assisted suicide or euthanasia, say the researchers who analyzed them. 
 
 “When you actually try to implement it even in a setting where there is excellent healthcare, there are a lot of red flags that need to be investigated further,” said lead study author Dr. Scott Kim, a psychiatrist and bioethicist at the National Institutes of Health in Bethesda, Maryland. 
 
 In some form, assisted death is legalized in Belgium, The Netherlands, Switzerland, Luxembourg, Canada and a few U.S. states, Kim and his colleagues write in JAMA Psychiatry. 
 
 “In Belgium and The Netherlands they have a much more expansive law that doesn’t regard diagnosis as important,” Kim told Reuters Health. The ambiguity allows the law to also apply to patients with psychiatric illnesses. 
 
 People with treatment-resistant depression tend to be the focus of debate over assisted suicide for psychiatric illnesses, the researchers note. But little is known about who actually uses the 2002 law that formalized euthanasia practices in the Netherlands. 
 
 For the new study, the researchers examined case summaries from Dutch regional euthanasia review committees posted online by June 2015. The committees are charged with ensuring that “due care” was given by the doctors involved in each case. 
 
 There were 66 summaries of psychiatric assisted suicide cases that took place between 2011 and 2014, representing the majority of assisted suicides involving psychiatric patients known to have occurred during that period. 
 
 Overall, about a third of the people helped to end their lives were age 70 years or older, 44 percent were between ages 50 and 70 and about a quarter were 30 to 50 years old. Seventy percent were women. 
 
 While fully 55 percent of patients were diagnosed with depression, the others had a number of different conditions, including psychosis, posttraumatic stress disorder or anxiety, neurocognitive issues, pain without any physical cause, eating disorders, prolonged grief and autism. 
 
 About a quarter of patients’ suicides were assisted by psychiatrists, and about one in five patients were treated by unfamiliar doctors - the majority from a mobile assisted suicide clinic funded by a Dutch right to die organization. 
 
 The researchers also found that about one in 10 patients receive no outside input from psychiatrists, and about a quarter of cases involved disagreement between the doctors treating the patient. 
 
 Dr. Paul Applebaum writes in an accompanying editorial that the findings “raise serious concerns about the implementation of physician-assisted dying for psychiatric patients.” 
 
 For example, over half of the cases also had personality disorders, which raises questions about “the stability of the expressed desires to die,” writes Applebaum, of the New York State Psychiatric Institute and Columbia University’s Department of Psychiatry in New York City. 
 
 When one considers the subjective criteria used to determine a person’s eligibility for assisted suicide or euthanasia in The Netherlands, Dr. Aaron Kheriaty said, it’s no surprise to see such a wide range of ages and psychiatric diagnoses among the patients who choose to end their lives this way. 
 
 “To me that’s very concerning,” said Kheriaty, a psychiatrist and director of the Medical Ethics Program at the University of California, Irvine. 
 
 Some of the conditions listed in the cases are potentially treatable, he said. 
 
 “I think when we open the door to assisted suicide for psychiatric patients, we risk abandoning patients when there may be hope,” said Kheriaty, who was not involved with the new study. 
 
 Kim said there is currently no standardized system for reporting these cases, and the availability of data varies by country. 
 
 “I think there needs to be a lot more transparency of what actually happens when assisted suicide or euthanasia is provided,” he said. “Right now the Dutch system is the most transparent.” 
 
 SOURCE: bit.ly/1SgP7Xs and bit.ly/1SgPaTp JAMA Psychiatry, online February 10, 2016.
– Euthanasia is itself not without controversy; the euthanasia or assisted suicide (EAS) of the mentally ill even more so. It's an infrequent practice but one on the rise in the Netherlands, which is thought to have seen no more than five such cases in 1997 but 42 in 2013. Still, "little is known" about these cases, write researchers in a report published Wednesday in JAMA Psychiatry. And so they reviewed the particulars of 66 patients who opted for EAS in the country from 2011 to 2014. Depression was the most common psychiatric disorder, but there was also psychosis, PTSD, and anxiety and long-term eating disorders (most had more than one condition). About half had attempted suicide; almost all had a comorbidity (ranging from cancer to arthritis), though the study calls out one healthy 70-year-old woman who simply found her life a "living hell" in the year after her husband's death. As for how they came to end their lives, "the reality of implementing such programs is messy," Reuters notes. In 32% of the cases, the patient had been refused EAS. The physicians for three of those 21 patients ultimately reversed their decisions; the other 18 got approval from a new physician. In 24% of the cases, there was physician disagreement, per a press release, and the New York Times points out that while most patients had long treatment histories, 56% had turned down at least some treatment. In an accompanying editorial, Dr. Paul S. Applebaum sees further "red flags," among them the 20% who had never been hospitalized for psychiatric reasons, the "ratio of women to men (2.3 to 1), and the 56% of cases in which social isolation or loneliness was important enough to be mentioned," raising "the concern that physician-assisted death served as a substitute for effective psychosocial intervention." (Belgium granted a depressed 24-year-old the right to die.)