MAiD in Canada: Treatment Resistant Depression
See accompanying MAiD in Canada and Sex.
Illustration: Meds © created by Billiam James
The provision of Medical Assistance in Dying (MAiD) is under review in Canada with debate about access for patients with mental illness.
An amendment to the draft legislation eliminating the exclusion of people with mental illness was proposed by Senator Stan Kutcher, arguing mental illness is as real as physical illness, that it can lead to great distress and people taking their own life in any event.
In recent years in some European countries patients have accessed MAiD for Treatment Resistant Depression (TRD). The most notable cases have been younger women.
Arguments against this amendment express concern that people with mental disorders may be pressured to opt for death, essentially for the convenience of others and of services that are not adequately funded.
Some have argued that mental disorders are somehow immaterial in contrast to physical disorders. Major medical groups in response claim mental disorders are as physical as any other disorders.
Real or Not?
The position adopted here is that mental illnesses are real illnesses. By this is meant that conditions like schizophrenia and manic-depressive illness involve physiological dysfunction and are not immaterial in some way, attitudinal, or simply distress.
Before 1980, mainstream psychiatry did not regard personality disorders or what used to be called neurotic disorders as biological illnesses. The Third Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM III) published in 1980, attempting to bridge a divide between psychodynamic and biological psychiatry and claiming to be agnostic about the nature of mental conditions, collapsed distinctions between neuroses and diseases into the category of disorders.
Some of what are now called mental disorders involve conditions that have been traditionally viewed as underpinned by physiological disturbances as much any physical illness. Others do not. Disorders like schizophrenia and manic-depressive illness are as much brain illnesses as epilepsy. The personality disorders and neurotic disorders also coded in DSM III are not brain illnesses like epilepsy. If illness in the sense of physiological dysfunction is a key criterion for MAiD, a case can be made for excluding these disorders. But there is a complicating factor.
Curability
Bearing in mind the hazard of diagnostic imprecision, unlike other psychoses, schizophrenia has traditionally been viewed as incurable. (It is possible that a patient diagnosed as having schizophrenia might present to a doctor who correctly suspects the diagnosis is wrong and the patient can be cured).
Hardcore schizophrenia is now somewhat remediable. Patients with other psychoses can show complete recovery between episodes as much as patients with arthritis for instance.
Schizophrenia is at present declining in frequency for reasons that are unclear but probably link to an environmental factor such as lead (this illness was not present before the mid-nineteenth century).
Manic-depressive illness is an episodic illness with patients making a full recovery between episodes. A century of admissions to asylums before we had any treatments for either mania or depression offer enough data to work out whether these conditions ever failed to recover. Essentially none failed to recover. Even the most severe psychotic depressions that had to be tube-fed recovered on average in 5-6 months, with fewer relapses than happen now.
TRD was an unknown concept before the advent of modern pharmaceuticals. The examples of Enduring Sexual Dysfunctions induced by treatment (See MAiD and PSSD) and the protracted withdrawal syndromes people trying to get off antidepressants suffer attest to the risks of treatments creating conditions that never existed before.
TRD is a retread of Treatment Resistant Schizophrenia (TRS). TRS originally referred not to a treatment resistant condition but a group of patients more likely to respond to clozapine than other antipsychotics. This was a polite way to tell doctors that giving their patients clozapine, which could not be safely given in high doses, would stop them poisoning patients, who as a result would benefit, sometimes significantly.
The radical step of stopping doctors poisoning patients is not an option with antidepressants in that several million Canadians now on them are simply unable to stop. Many of these patients do not benefit from treatment other than in so far as it staves off withdrawal.
TRD is a marketing construct aimed at adding additional treatments to the mix the patient is already on. Pharmaceutical companies are using conditions their products have created to market yet further products that far from alleviating the index conditions are more likely to aggravate the problems, which companies will use to create further markets.
MAiD and TRD 1
The group of conditions subsumed under the heading of TRD are a set of serious and incurable physical illnesses.
They are the physical consequences of treatments some of which are given for mental disorders (personality disorders and neuroses) and others for physical conditions.
The distress TRD causes appears to be as intense as is the distress caused by conditions that have hitherto led people to seek out MAiD.
There are at present no clear prospects for a cure of the condition or for relief from distress.
MAiD and TRD 2
There have been concerns that people may be pushed toward the irrevocable step that is MAiD because families or the State do not offer supports that might make a difference and these supports are less likely to be developed if MAiD is made too easy.
TRD suggests another factor should be considered.
These conditions result in part because the entire medical literature on on-patent drugs is ghost-written and there is no access to the data from healthy volunteer and clinical trials that were undertaken to bring these drugs on the market.
The data make it clear that these conditions were foreseeable. With access to the data the conversations between doctors and patients would likely have been quite different.
The core issues are laid out in a Healy lecture for the Therapeutics Initiative on Feb 10th, the video of which, along with text and slides can be accessed Here
Senator Kutcher was an ‘author’ on a famous study of paroxetine given to adolescents commonly referred to as Study 329. The paper was ghostwritten. It is unlikely Dr Kutcher has had access to the trial data other than the patients he himself entered into the study. Study 329 led New York State to file a fraud action against GlaxoSmithKline, the makers of paroxetine, and in 2012 the US Department of Justice to take an action against GlaxoSmithKline that resulted in the then largest sum handed over to resolve a corporate case of this kind – $3 Billion (USD).
The process of ghostwriting articles and sequestering clinical trial data began in earnest a little over 30 years ago and since then the time between doctors becoming aware of and generally accepting the hazards of their treatments has increased from roughly a year to several decades. The aggressive marketing of TRD meanwhile makes it very difficult for anyone now to recognize these conditions for the treatment induced conditions they are.
In the case of adolescents given antidepressants, there have been 30 trials undertaken all negative, but mostly portrayed in the medical literature as positive, with the trial Dr Kutcher was involved in being the most striking example of a negative trial of an unsafe drug that was written up as effective and safe.
The upshot of this is that on the one hand we have the greatest concentration of Evidence against a set of treatments ever assembled but those treatments are now quite possibly the second most used drugs by adolescent girls who are unlikely to benefit and highly likely to be harmed.
This is the group of patients with ‘mental illness’ now most notably accessing MAiD in Europe. Young Canadian women with TRD, put in this position at least in part by practices that prioritize commercial considerations over scientific, moral or clinical considerations, are likely to turn to the same option. Any extension to current legislation should ideally address this question.
David Healy MD February 17th 2021.
This post is one of two attachments to a letter to 3 Canadian Members of Parliament.
For those new to the Enduring Sexual Dysfunctions – PSSD, PGAD, PFS and PRSD – mentioned on David Healy there is a page about them on RxISK.org along with a good deal of published literature that can be downloaded. There are many additional posts on RxISK about both these conditions and Treatment Resistant Depression.
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MAiD and mental illness? This is very dangerous and should not ever be considered. I am even shocked they are even going to debate it! We are living in very scary times. People should not be allowed to make such a decision if mentally impaired or on any psychiatric treatments because they may very well feel the opposite when in a changed mental state, ie no longer mentally impaired or on any psychiatric treatment.
Unbelievable this is even up for discussion.
Indeed, mental illness is as real as physical illness however, I question the inaccurate tools of misdiagnosis practitioners have been utilising in an obscure manner, for a limitless amount of time.
It is certainly unconscionable that anyone could propose such a preposterous debate and even consider cementing it into any form of legislation.
If someone is mentally impaired especially due to some of the tools practitioners are so underhandedly taking advantage of, how can they put forward such a debacle.
Some patients are of ‘not sound mind’ when they are under the influence of these medicines particularly when doctors prescribe so many medicines at one given time. It is no different to one who is under the influence of alcohol or recreational drugs.
I am convinced that a proposal of such thoughtless magnitude can certainly bring such dire consequences.
The right to die under such circumstances is fraught with legal/moral/ethical implications, that is not only open to abuse but misinterpretation.
Let me put forward a case scenario:
A patient who comes into a physician’s office, already displaying signs of clinical depression, is prescribed a medicine for their condition. Within a few weeks, the prescribed medication does not work effectively according to plan and so another medication is prescribed to determine its effectiveness. If for some unfortunate reason, the patient ends up ‘mentally’ worse than what they came in with, it can certainly lead to unnecessary suffering and potentially lead to an inexcusable death. The medicine(s) may have put the poor patient into an abysmal ‘gridlock’, through no fault of their own. How can anyone condone such unacceptable psychiatric treatment, such as MAiD, under another unwarranted legislation?
One cannot possibly use the assumption or paradox to assume the everyone has the right to die under these abhorrent conditions.
I will not give anyone the right to judge or even utter the words to say it is someone’s choice especially when a case such as the one I mentioned is out of the persons control.
The above case study, given time and appropriate ways to heal, may have a second chance to life, without unnecessary pain or suffering. This is why practitioners always have to find other less harmful alternatives for patients because the above scenario can happen to anyone. Unless, we use technology wisely to determine if patients are combatable to certain medicines, some practitioners should always err with caution, before prescribing. It’s like a stab in the dark.
The area of healing mental illnesses, should be explored and exhausted until one finds ‘a compatible fit’ for the individual.
Healing mental illnesses is not just confined to pills.
Medicine has come a long way for assisting and helping many with psychiatric disorders however, if these mental illnesses are induced by prescribed medicines there has to be a way to detoxify the patient without harming the brain. Western Medicine has a long way to go before they can achieve this without harming people.
For this reason, I totally am in agreeance with what Anne-Marie KELLY has so convincingly stated:
People should not be allowed to make such a decision if mentally impaired or on any psychiatric treatments because they may very well feel the opposite when in a changed mental state, ie no longer mentally impaired or on any psychiatric treatment.
I am sure that many people who are conscientious would have no objection to the case I have put forward. If they did, our standards of care and compassion are slowly diminishing and the factors that maintain societal cohesion are coming undone. Society will slowly start to collapse if we allow unethical conditions to make its way into the system.
Some patients are of ‘not sound mind’ when they are under the influence of these medicines particularly when doctors prescribe so many medicines at one given time. It is no different to one who is under the influence of alcohol or recreational drugs.
Exactly being on prescribed psychiatric drugs is no different to being under the influence of alcohol or recreational drugs. Why can they not see this obvious fact?
You can’t be assessed by a psychiatrist or interviewed by the police if your under the influence of alcohol or recreational drugs yet they ignore the effects psychiatric drugs have on a person.
You couldn’t make this up if you tried.
Yes Anne-Marie Kelly, common sense subjects are never debated.
We are viewed as criminals if we analyse such subjects.
Too many people are dying through no fault of their own and the current ‘modus operandi’ has to change.
I think we do need to remember that the ones suffering from PSSD etc. or have been told that they fit in to the TRD scenario are, as groups, pushing forwards for MAiD to be made available to them. In their desperation, they see no way out other than death. The CAUSE of their suffering is where we should be aiming our energies, I feel, in an attempt to ensure that they, the present sufferers, WILL BE THE LAST.
If we merely concentrate on a mode of death then we leave generations to come who will suffer in exactly the same way.
There are bound to be those who will push for MAiD for these groups – often ones who would probably like all criticisms of prescribed drugs to die alongside the sufferers. It is extremely sad that ANYONE, by doing nothing more than taking a medication as prescribed, has been pushed so far that they can find no joy whatsoever in living.
I find it interesting that comments, here and on David’s blog, from those who have experienced other adverse effects, are totally against the inclusion of “mental health cases” in assisted death rights. I have checked with my own son, who, as many of you will know, has suffered from prescribed medication adverse effects – he is also TOTALLY against assisted dying in all its forms. He only agrees with palliative support in dying as happens to someone in a vegetative state.
All the love and care and compassion in the world will not alter a profound wish to die All the talking and promises of a better future become futile At the deep end there is little meaningfull attachment to life itself , It is not heartless but people and society are not worth hanging on to compared to the unremitting bleakness of loss of any joy in living or the horror of drug induced loss of identity or the shocking realisation that bizarre drug induced symptoms might never end. Nobody can judge this for another . Many who would want assisted deaths are put off by the bureaucratic mannner being proposed for ending something as sacred as a life. As assisted death is the issue here I would avoid any attempt at my own death being ‘assessed’ in such a vile way that a group of psychs would decide to monitor and decide for me that the time is ripe. The decision for people with mental illnesses can be as rational as anybody elses in times of remission. To put people with mental health histories in yet another category as unable to make that decision denies the same rights as others to excercise autonomy over their own lives. There are better options than medically assisted deaths but neither they or the alternatives are foolproof.
All Professionals are still not requesting to have a copy of an Advance Decision or advising people to make one – There are some which explain the way to set this out for anyone with a mental health issue , it is worth taking a look at several as they can be a little different and some are specific about advice for people with mental health issues. When an attempt at suicide fails there is still the right to decide on what treatments are not acceptable. Some orgs still oppose the total right to die without certain conditions attached , such as stipultating a wait of so many months rather than leave that to the person making a decision to have an assisted death. To be tossing these things up at all is shocking but To live like a ghost cut off from life is not something everyone wants to tolerate.
Anon, I was in a state of total darkness because of what the meds did to me and yes, I too wanted to die.
Thank goodness, I did not resort to such dark thoughts or else I wouldn’t be here writing/creating awareness/debating or challenging.
You have a right to your opinion as others have a right to theirs.
We have been impacted, have some clarity and insight into what is really going on when meds are misused and abused.
We understand how it impacts the delicate ‘hard wiring ‘of the brain and we appreciate that once one is able to come out of the ‘dark abyss’ these meds induce, there is indeed, light at the end of the tunnel.
Once the dark clouds lifted and my mindset changed, life was worth living despite all the health challenges that were and are still are ahead of me.
Like Anne-Marie KELLY stated:
People should not be allowed to make such a decision if mentally impaired or on any psychiatric treatments because they may very well feel the opposite when in a changed mental state, i.e. no longer mentally impaired or on any psychiatric treatment.
Drug induced depression does your head in and I cannot justify death as a means to an end.
People deserve second chances in life and I am so glad I am alive.
I would love to leave you with a quote because I am sure that many who have pulled through would tend to resonate with it.
When I stand before God at the end of my life, I would hope that I would not have a single bit of talent left and could say, ‘I used everything you gave me.’
~ Emma Bombeck
This is why we come to RXISK because it is our calling, our passion and of course our way of giving back to people who are and were in the same situation that we once were in. We hope that we can prevent misfortunes so that other souls do not have to suffer the way we did. RXISK gives us meaning and purpose to do what we believe is right.
I would just clarify that people I have known, who did end their lives, were not mentally impaired when they took that considered decision. It was not for others to ‘allow’ them to die or to prevent them. It is difficult for most to understand that everyone does not want to be saved from death It is welcomed.. And they don’t have thoughts of whether they ‘deserve ‘ a second chance. They have not done anythong ‘wrong’. I am glad you are happy with your own decision but as you say others have different perspectives Suicide is not the worst option for some But I do consider an assisted death as proposed , inhumane , Many have contributed to life in their own way without believing they need to justify their decision to a higher god or indeed contribute to Rxisk and other forums to help others and give meaning to their life in that way. Of course it is good that this is a way many like yourself do find supportive and gives meaning to a wish to help others.Their own value and talents may lie in other directions Including to try to attempt to help others understand that death is not simply a last ditch solution because all else has failed. They have not failed, life has failed them. It is not for others to judge those who do not share your opinions on ‘what is right’. That attitude has made life hell for many who go against the grain of what is considered ‘right’ -until times change (eg abortion) I leave you with this thought -Remember suicide was still a crime up to not so long ago. There are still remnants of that attitude existing now,
Some men aren’t bothered about losing hair – others end up on ADs , Some as a result take their own lives. Advertising is still legal for Isotetrinoin knowing how much some men are effected by anxiety about their attractiveness and romantic /sexual lives. Knowing this ,how much longer MHRA ?
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Update on isotretinoin call for information
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Engagement
9:40 AM (1 hour ago)
to Engagement
Dear Colleague,
We would like to thank you and everyone who has contributed to the call for information as well as those who have shared the links within their organisations or networks. We appreciate the time you have taken to share your views on this important issue.
We received 710 responses from a range of people. This included those who have received isotretinoin, family members or friends of someone who has taken isotretinoin, and from healthcare professionals who have either treated individuals with isotretinoin or have treated suspected side effects of isotretinoin.
All responses will be considered by the Isotretinoin Expert Working Group and again we wish to reassure you that all personal details will be removed when this information is assessed and discussed in the Group.
We will inform you of next steps of the review shortly.
If you require further information, please email MHRACustomerServices@mhra.gov.uk.
Hello David,
Trust all s well.
If you place my comment on risk, can you please put this one and not the first one.
Anon, I need to clarify the situation before my views are misinterpreted.
Sorry, Anon, I am not writing about voluntary suicide.
I am debating drug induced depression.
Certain medicines impact peoples brains, in certain ways.
Many innocent people end their lives because of what the drugs induce.
This is totally out of their control.
I have not written about voluntary suicide.
These are two separate issues.
Yes, I completely feel for people who end their lives, whether it is drug induced or voluntary suicide.
Anon – thanks for clarification. I still disagree with your position re ‘voluntary’ I am also talking about people who were effected by prescribed drugs. Those who do are able to make decisions to end their lives despite being effectd by drugs. decisions to die can be made both during illness and during remission. An agument isn’t useful about whether the drugs are a cause , that isn’t necessary in my opinion. The decision can still be voluntary when a person knows drugs are a cause of despairing feelings And they often report that they are the cause and this is ignored – which can lead to a decision of suicide.
Are you people for real? Is this MD for real, saying “Essentially none failed to recover. Even the most severe psychotic depressions that had to be tube-fed recovered on average in 5-6 months, with fewer relapses than happen now.” This is completely false. How can such a lie be stated.
What is being said against MAID and those who really do suffer intolerably for years from intolerable suffering is beyond idiotic. The suffering is real people. Many are helped by talk therapy, and perhaps meds (although I am skeptical), some people are not. Their lives are destroyed. They lose their jobs, their families, their life. This is a fact, despite many of them being highly intelligent and capable individuals, who have received the best care possible. Wake up! I encourage you to google Adam Maier-Clayton, and read his story. Most importantly, listen to what his mother has to say.
Gus
Have written a whole post as a special reply for you
https://rxisk.org/m-a-d-and-treatment-resistant-depression/
David
People who are truly depressed and want to die are going to do it whether you want them to or not. That’s the reality. However, not all depressed people want to die. For those who do, isn’t it much kinder to let these people to do it without shame, without secrecy and without through such horrific methods?
I’ve been depressed for 22 years with no end in sight. I’m not stupid or ignorant and I’m not just thinking about it on a whim. True depression is HARD to deal with. I do hope to be granted MAiD in 2023. Maybe I will go for it and maybe I won’t. But I do feel a great deal of comfort knowing that it might be soon there for someone like me.
This is a great piece, informative, and well-written. I believe that many of us are experiencing this mental condition where we cannot find a solution to the physical or psychological symptoms that manifest when life becomes difficult or perhaps even out of the blue. Thank you for sharing this. It is such a great help to people who needs to read this.