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(1) Assisted suicide laws may overlook depressed patients
(2) Has a new era of reinstitutionalistion in mental health care begun?
(3) Tobacco smuggling is killing more people than illegal drugs

(1) Assisted suicide laws may overlook depressed patients
(The prevalence of depression and anxiety in patients requesting physician aid in dying )
http://www.bmj.com/cgi/content/abstract/337/oct07_2/a1682
(Editorial: Depression and Physician-assisted dying)
http://www.bmj.com/cgi/content/extract/337/oct07_2/a1558

One in four terminally ill patients in the State of Oregon who opt for physician assisted suicide have clinical depression and the Death with Dignity Act may not be adequately protecting them, concludes a study published on bmj.com today.

In 1997, the State of Oregon passed the Death with Dignity Act that allows physician assisted dying for terminally ill patients.

The extent to which potentially treatable psychiatric disorders may influence patients' choices to hasten death is hotly debated. There are several safeguards in the Act to ensure patients are competent to make the decision to end their life. This includes referral to a psychologist or psychiatrist if there is concern that a patient's judgment might be impaired because of mental illness.

However, it is well known that health care professionals often fail to recognise depression among the mentally ill. In 2007, none of the 46 Oregonians who died by lethal ingestion were evaluated by a psychiatrist or a psychologist.

Dr Linda Ganzini and colleagues from Oregon Health and Science University, assessed 58 Oregonians who were terminally ill and had requested physician assisted suicide or contacted an aid in dying organisation, to determine if they had depression or anxiety. The authors used standardised measures including questionnaires and interviews to assess depression and anxiety in the participants.

The researchers found that the current practice of legalised assistance with dying allowed some potentially ineligible (clinically depressed) patients to receive a lethal prescription.

Fifteen of the participants met the criteria for depression and 13 for anxiety. Forty-two patients had died by the end of the study, 18 received a prescription for a lethal medication under the Act and nine died by lethal ingestion. Fifteen who received a lethal prescription did not meet the criteria for depression, three did, and all three died by lethal ingestion within two months of the research interview.

Although the authors acknowledge that most patients who request aid in dying do not have a depressive disorder they point out that "the current practice of Death with Dignity Act may not adequately protect all mentally ill patients" and call for "increased vigilance and systematic examination for depression among patients who may access legalised aid in dying."

In an accompanying editorial, Dr Marije van der Lee from the Helen Dowling Institute in the Netherlands, says that while it is vital to protect vulnerable patients, examining terminally ill patients to determine if depression is impairing their judgement is complex.

She believes that depression does not necessarily impair judgement and says that in the Netherlands what is most important is that the patient makes an informed decision. She concludes: "we should focus on trying to 'protect' patients from becoming depressed in the first place, rather than focus on protecting patients from assisted suicide."

Contacts:
Linda Ganzini, Department of Psychiatry, Oregon Health and Science University Oregon, USA
Email: newmanj@ohsu.ed
Marije van der Lee, The Helen Dowling Institute, Utrecht, Netherlands>/br> Email: mvanderlee@hdi.nl

(2) Has a new era of reinstitutionalistion in mental health care begun?
(A retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and the number of psychiatric beds in England 1996-2006)
http://www.bmj.com/cgi/content/abstract/337/oct09_2/a1837
(Editorial: Availability of inpatient beds for psychiatric admissions in the NHS)
http://www.bmj.com/cgi/content/extract/337/oct09_2/a1561

The number of compulsory admissions to inpatient psychiatric care has increased dramatically but the number of NHS beds has fallen, and there has also been a significant increase in the number of patients admitted for alcohol and drug problems, finds a study published today on bmj.com.

In addition, inpatient psychiatric care is expensive, unpopular, and often unsatisfactory, says the author of an accompanying editorial.

Since the 1950s deinstitutionalisation has resulted in the number of psychiatric beds declining from 150,000 in 1955 to less than 55,000 in 1995. But evidence suggests that involuntary admissions are increasing and that perhaps a new era of reinstitutionalisation has begun.

Patrick Keown and colleagues examined the changing face of psychiatric care in England between 1996 and 2006 by analysing data from the NHS Information Centre, the Department of Health, and the 2006 'Count me in' census.

Overall, they found that while total psychiatric admissions and NHS bed numbers fell during the decade, the number of patients sectioned increased by 20%, with a threefold increase in the number of these involuntary patients being admitted to private facilities.

They report that as the number of NHS psychiatric beds decreased by 29%, the proportion of NHS beds occupied by patients admitted under a section of the mental health act increased from 23% in 1996 to 36% in 2006. In 1996-7 sectioned patients were 15 times more likely to be in an NHS facility than a private facility, but by 2006 they were only five times more likely.

Total NHS admissions for mental disorders peaked in 1998 at around 214,000 and then began to fall. Reductions in admissions were confined to patients suffering from learning disabilities (decreased by 58%), depression (33%) and dementia (28%). Admissions for other groups such as schizophrenic and manic disorders have remained relatively stable, however, and since 2003 those for drug and alcohol problems have increased by 29%.

The authors say that the change in case-mix towards psychotic, alcohol and substance misuse disorders has changed the environment on inpatient psychiatric wards.

In an accompanying editorial, Professor Scott Weich, Professor of Psychiatry at the University Warwick, argues that the focus should move away from numbers to the quality of service provision. The absolute bed numbers, he writes, say nothing of the differences between places and service users, or the quality of services and the experiences of users, carers, and staff.

The greater need is for improvements in the quality of services and "this will only happen if users' and carers' voices are heard and acted on", he concludes.

Contacts:
Patrick Keown, Consultant Psychiatrist and Honorary Senior Lecturer, Newcastle, UK
Email: p.j.keown@newcastle.ac.uk
Editorial: Scott Weich, Health Sciences Research Institute, University of Warwick, Coventry, UK
Email: s.weich@warwick.ac.uk

(3) Tobacco smuggling is killing more people than illegal drugs
(Analysis: Why combating smuggling is a priority)
http://www.bmj.com/cgi/content/extract/337/oct09_2/a1933

Tobacco smuggling causes around 4,000 premature deaths a year - four times the number of deaths caused by the use of all smuggled illegal drugs put together - but the UK government is not doing enough to tackle the problem, claim experts on bmj.com today.

Professor Robert West from the Cancer Research UK Health Behaviour Research Centre and colleagues argue that more smokers would quit if cigarettes cost more, but at around half the price, smuggled tobacco is keeping the prices down.

Around 21% of all tobacco smoked in the UK is smuggled into the country. If there were no smuggling, the price of legal tobacco would increase by around 12%. According to the authors, this would lead to 5-8% of smokers kicking the habit - saving at least 4000 lives a year.

A reduction in tobacco smuggling would also help reduce health inequalities because low income smokers are more likely to use smuggled tobacco and they are also more likely to quit because of price increases.

While the authors acknowledge that tobacco smuggling has reduced considerably since the government 'Tackling Tobacco Smuggling' strategy was announced in 2000, they argue that more needs to be done and call for more action and resources to tackle the problem.

For example, the UK government has not followed the lead of all the other European Union countries and has failed to sign up to legally enforceable agreements with the two tobacco companies, Philip Morris International and Japan Tobacco International, to ensure that they tightly control and regulate distribution and stop supplying contractors involved in smuggling.

The authors point out that because public targets for reducing smuggling into the UK were dropped in March this year, the HM Revenue and Customs can no longer be held publicly accountable for performance in this area. They believe that when the new UK Border Agency take over responsibility for cross-border control later this year, there will be a risk that tobacco smuggling will be sidelined by the main focus of immigration.

They conclude by urging the UK Government to set out comprehensive measures and clear targets for the UK Border Agency to control the illegal tobacco, and for the government to support negotiations, currently underway, for a strong international treaty to tackle smuggling.

Contact:
Robert West, Cancer Research UK Health Behaviour Research Centre, University College London, London, UK
Email: robert.west@ucl.ac.uk

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