Depression as a terminal illness

Is there a place for palliative care?


In 2020, there were 5,224 suicide deaths registered in England and Wales.1 The Mental Health Foundation, a London-based charitable organization, reports that approximately 70% of such deaths are in patients with depression.2 The number of attempted suicides is much higher – the South West London and St. George’s Mental Health Trust estimates that at least 140,000 people attempt suicide in England and Wales every year.3

In suicidal depression, the psychological pain is often unbearable and feels overwhelmingly incompatible with life. One is no longer living but merely surviving, and eventually the exhaustion will lead to decompensation. This is marked by suicide. The goal is to end the suffering permanently and this is achieved through death.

Dr. Minna Chang, Imperial College London

Dr. Minna Chang

Depression, like all other physical and mental illnesses, runs a course. This is highly variable between individuals and can be the case even between separate relapse episodes in the same patient. Like many diagnoses, depression is known to lead to death in a significant number of people. Many suicidally depressed patients feel that death will be an inevitable result of the illness.

Suicide is often viewed as a symptom of severe depression, but what if we considered death as part of the disease process itself? Consequently, would it be justifiable to consider depression in these patients as a form of terminal illness, since without treatment, the condition would lead to death? Accordingly, could there be a place for palliative care in a small minority of suicidally depressed patients? Taking such a perspective would mean that instead of placing the focus on the prevention of deaths and prolonging of lifespan, the focus would be on making the patients comfortable as the disease progresses, maintaining their dignity, and promoting autonomy.

Suicidal depression and rights

Patients with psychiatric conditions are generally not given the same rights to make decisions regarding their mental health and treatment, particularly if they wish to decline treatment. The rationale for this is that psychiatric patients do not have the capacity to make such decisions in the acute setting, because of the direct effects of the unwell mind on their decision-making processes and cognitive faculties. While this may be true in some cases, there is limited evidence that this applies to all suicidally depressed patients in all cases.

Another argument against allowing suicidally depressed patients to decline treatment is the notion that the episode of depression can be successfully treated, and the patients can return to their normal level of functioning. However, in individuals with a previous history of severe depression, it is possible that they will relapse again at some point. In the same way, a cancer can be treated, and patients could return to their baseline level of functioning, only for the cancer to then return later in life. In both cases, these relapses are emotionally and physically exhausting and painful to get through. The difference is that a cancer patient can decline further treatment and opt for no treatment or for palliative treatment, knowing that the disease will shorten life expectancy. For suicidal depression, this is not an option. Such patients may be sectioned, admitted, and treated against their will. Suicide, which could be considered a natural endpoint of the depressive illness, is unacceptable.

Is it fair to confiscate one’s right to decline treatment, solely because that person suffers from a mental illness, as opposed to a physical one? Numerous studies have demonstrated clear structural, neurological, and neurochemical changes in suicidal depression. This is evidence that such a condition encompasses a clear physical property. Other conditions, such as dementia and chronic pain, have previously been accepted for euthanasia in certain countries. Pain is a subjective experience of nociceptive and neurochemical signaling. In the same way, depression is a subjective experience involving aberrant neurochemical signaling. The difference is that physical pain can often be localized. However, patients with suicidal depression often experience very severe and tangible pain that can be difficult to articulate and for others to understand if they have never experienced it themselves.

Like distinct forms of physical pain, suicidal depression creates a different form of pain, but it is pain, nonetheless. Is it therefore fair for suicidally depressed patients to be given lesser rights than those suffering from physical illnesses in determining their fate?


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