Saturday, August 11, 2018

Treating Depression with Poison

We are more than grateful for the new psychiatric treatments for depression. You would think, by reading the papers, that we have finally conquered it. We can offer SSRIs, other assorted medications and even, in extreme cases, electroshock therapy. Beyond that there is cognitive behavioral therapy and physical exercise. For bipolar depression we have lithium.

All told, psychiatry has done creditably with depression. And, one must assume, scientists are hard at work on new treatments. Hope is there. We have reason to be optimistic. We have reason to believe that we can treat any case of depression.

And yet, how does it happen that a supposedly civilized country like the Netherlands can prescribe lethal poison as a treatment for seemingly intractable cases of depression. It’s called assisted suicide, and it is offered only to patients who request it. Who insist on it. Who proclaim that their illness is positively incurable.

The BBC has reported on the case of Aurelia Brouwers. (via Maggie’s Farm) It's not just that she insisted that euthanasia was the only solution to her problem. We note that the lead up to the execution, or self-poisoning was televised.

Civilized European nations reject capital punishment. They do not do as the Chinese do, and execute people in public, in stadia, where everyone can watch.

But, they are willing to follow Aurelia Brouwers around for two weeks, watching her get ready to drink state-provided poison. They are making her a celebrity, a martyr of sorts. They are offering her fame in exchange for her life. Do you really think that that is civilized?

BBC tells the story:

In January a young Dutch woman drank poison supplied by a doctor and lay down to die. Euthanasia is legal in Holland, so hers was a death sanctioned by the state. But Aurelia Brouwers was not terminally ill - she was allowed to end her life on account of her psychiatric illness.

"I'm 29 years old and I've chosen to be voluntarily euthanised. I've chosen this because I have a lot of mental health issues. I suffer unbearably and hopelessly. Every breath I take is torture…"

A team from the Dutch TV network, RTL Nieuws spent two weeks recording Aurelia as she journeyed towards her date with death - 2pm on Friday, 26 January. On a whiteboard in her home, she crossed off the days with a heavy black marker pen.

During those last weeks, she spent her time with loved ones, doing craftwork and riding her bike in Deventer, the city she adored. She also visited the crematorium - the place she had chosen for her own funeral service.

Euthanasia is becoming more common in Holland. Nearly 7,000 terminally ill patients chose it last year. Of those, 83 were suffering from psychiatric illnesses.

Brouwers explained her mental illness:

Aurelia Brouwers' wish to die came with a long history of mental illness.

"When I was 12, I suffered from depression. And when I was first diagnosed, they told me I had Borderline Personality Disorder," she says. "Other diagnoses followed - attachment disorder, chronic depression, I'm chronically suicidal, I have anxiety, psychoses, and I hear voices."

One will be forgiven for questioning the competence of Dutch psychiatrists. The woman had a slew of illnesses, most of which are treatable… and yet, all treatments seemed to have been ineffective. We do not know which treatments she received. Her physicians refused to give up on her, so she went to a euthanasia clinic where everyone is more sympathetic and understanding. And where they tell her that she is a hopeless case.

Some Dutch psychiatrists are not at all persuaded that assisted suicide should be added to the list of accepted treatments for chronic depression:

"How could I know - how could anybody know - that her death wish was not a sign of her psychiatric disease? The fact that one can rationalise about it, does not mean it's not a sign of the disease," says psychiatrist Dr Frank Koerselman, one of Holland's most outspoken critics of euthanasia in cases of mental illness.

He argues psychiatrists should never collude with clients who claim they want to die.
"It is possible not to be contaminated by their lack of hope. These patients lost hope, but you can stay beside them and give them hope. And you can let them know that you will never give up on them," he says.

Koerselman makes an important point. If psychiatrists collude with the patient’s hopelessness, doesn’t that encourage the patient to want to die? Isn’t it more humane to always believe that something can be done, that something new will be discovered or that the illness will eventually subside?

Consider the case of Monique Arend, another Dutch woman with borderline personality disorder:

Monique Arend, like Aurelia Brouwers, was diagnosed with psychiatric illness including Borderline Personality Disorder. People with this condition may self-harm, have intense feelings of anger, find it hard to sustain relationships, and experience emotional instability. Monique made many attempts to kill herself.

"It happened everywhere - at home, in the forest... But I'm very grateful I'm still alive today," she says.

Monique is a survivor of violent sexual abuse, and terrifying psychiatric episodes. She thought long and hard about euthanasia.

"I thought I was a big problem for everyone, and I just didn't want to be that burden, and the pain became unbearable. So I requested the forms for euthanasia, and filled them in. But I never filed them."

Monique did not file those papers because she found help. In the early days of her illness, a counsellor had advised her not to talk about the abuse - this is when she began to self-harm. But then she found a new therapist who specialised in trauma.

Think about it, Arend needed to find a psychiatrist who specialized in trauma. If other psychiatrists did not know what to do with a case of borderline personality disorder or with a trauma survivor, what were they doing?

Surely, these stories do not inspire confidence in psychiatry. Admittedly, Holland is not America. But, one can see from the list of diagnoses that were thrown at Brouwers that they were reading from the same playbook.


Korora said...

Since I have Asperger's, this makes me itchier than if I'd blundered into poison ivy.

Sam L. said...

A good reason not to live in The Netherlands.

David Foster said...

Tom Watson Jr, the longtime head of IBM, was afflicted with severe depression as a teenager. He got over it or at least got to the point of making it less disabling, probably getting away from home, learning to fly airplanes, and serving in the military were key points in his recovery.

I wonder how many similar stories there might be, and whether these Dutch shrinks have done the rigorous epidemeological studies which would be required in order to state that a patient has no significant chance of recovery?

Assistant Village Idiot said...

What we used to call Borderline Personality Disorder when I started my career is increasingly co-diagnosed, or even shifted entirely, to PTSD. Not all, but many. Treatment for both can be arduous, and despair is common. The worst cases end up living in institutions, so seriously suicidal that they cannot be out of hospital very long without another attempt. Hospitals don't want that liability and don't want to allow patients that much risk, even while knowing that is the best road to health. Everyone agrees in theory that risks are the only way to go, but the reality is that after a suicide, even one discharged months ago, hospitals can be blamed and sued.

Even without treatment, most improve slowly over time. Even terrible and disabling abuse gradually recedes if one takes care not to add to it. It seldom ever completely goes away, but people have friends, have lives, have jobs, have some pleasure in life. It is wrong for professionals to assist in suicide.

Anonymous said...

David Foster, these are two separate groups. Roughly, and without going into details, Dutch psychiatrists are bound by budgetary constraints. Doctors working at the End-of-Life Clinic however are bound by rules and protocols. They take more time with a client, because they have to. However, they are all pro-euthanasia, else they would not work there.

A perverse feature of the Dutch legislation on euthanasia is that the monitoring of compliance with the rules only takes place after the event. Experts who were critical about euthanasia have left those monitoring boards long ago.

The pro-euthanasia lobby has excellent contacts with several media, hence the Aurelia case could become such a media event. Her twitter account @AureliaBrouwers is still on line, reading the tweets one gets the impression that she was raving mad, but various Dutch artists came to support her. This support involved taking a picture together and publishing it on the internet. What would a dying person want a picture for??