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Schizophrenia and depression have long been associated with 

, an inability to experience pleasure. But recent clinical research suggests that patients with schizophrenia do in fact experience pleasure; they generally enjoy things like spending time with friends or doing well at work or in school. They just often have a hard time imagining and anticipating future enjoyment, and so they are not motivated to do the things that would make them happy.

How could psychiatrists address this motivational deficit? In this Mental Health Minute, Deanna Barch, PhD, discusses some of the emerging data from her research on 

in schizophrenia and depression. She suggests that different treatments may be necessary for these conditions, as they affect motivation and pleasure in different ways. She shares some of her early ideas about what forms these different treatments might take. 

 chair and professor of Psychology and Brain Sciences, professor of Radiology, and Gregory B Couch Professor of Psychiatry at Washington University in St. Louis.

How do you address motivational deficits in your patients? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

Being unable to experience pleasure and having difficulty imagining future enjoyment are different problems—and may require different treatments. 

New Directions in Addressing Motivational Deficits in Schizophrenia and Depression

included a Point/Counterpoint feature on electroconvulsive therapy (ECT). The feature elicited strong reactions from our readers. You can read the introductory essay, “Electroconvulsive Therapy: Obsolete and Dangerous or Still Just Misunderstood?” by Horacio A. Capote, MD, 

The authors of the original Point/Counterpoint have also continued their debate online. You can read a brief 

 for the opportunity to comment on the recent 

 articles in the April, 2021 issue on (ECT). The choice was presented as “

.” It is no choice at all: ECT is demonstrably safe and effective, but yes, still badly misunderstood.

ECT has evolved into a modern medical treatment for a limited number of psychiatric illnesses, primarily severe depression, but also psychosis and catatonia. ECT is what it is today, not what it was before modern general anesthesia, and needs to be objectively assessed, by true experts with recent experience in its use, and an understanding of the severity of the disorders it treats. We strongly support Michael E. Henry, MD’s position on ECT. He offers an accurate expert opinion based on evidence and experience. That is the information that should guide patients and physicians about ECT.

ECT has saved and improved countless lives, but as with any medical treatment or procedure, particularly one involving general anesthesia, there are risks and adverse effects; the decision to prescribe ECT always involves balancing those risks against potential benefits to the patient. That is the true, evidence-based process that expert ECT physicians follow when making a recommendation to consider ECT for a particular patient. Such a recommendation is never made cavalierly; it takes into account the severity and urgency of the psychiatric illness, the medical condition, and the treatment wishes of the patient. The informed consent process for ECT in the United States is comprehensive and follows modern ethical guidelines.

Unfortunately, misinformation perpetuates the stigma surrounding ECT. Attempts to discredit it are often based on ignorance of the realities of contemporary ECT, or worse, are ideologically driven and with questionable motives. ECT is not an ideology, a belief, or a religion. It is simply a medical procedure, with benefits and side effects. In truth there is no real point-counterpoint when one side is misinformation and distortions and the other side is medical fact.

Severe depression is disabling and sometimes life-threatening; until a worthy replacement for ECT is developed, patients and psychiatrists can be reassured that ECT is available when other treatments are ineffective. In knowledgeable medical circles, there is no controversy about that.

is the president of the International Society for ECT and Neurostimulation (ISEN). 

 is the chair of the Board of Directors of the ISEN.

A Psychiatric Times point/counterpoint feature on electroconvulsive therapy elicited strong responses.  

A Spirited Defense of ECT: From Our Readers

included a Point/Counterpoint feature on electroconvulsive therapy (ECT). You can read the introductory essay, “Electroconvulsive Therapy: Obsolete and Dangerous or Still Just Misunderstood?” by Horacio A. Capote, MD, 

 have agreed to continue their debate online. Ms. Hancock, Cunliffe, and Dr Read argue that ECT is 

. Representing the pro-ECT position, Dr Henry has responded to their article below.

I would also like to thank Sarah Hancock, MS, CRC, Sue Cunliffe, MBchB, RCPCH, John Read, PhD for responding to my article “

Their objections to electroconvulsive therapy (ECT) are primarily focused on the cognitive side effects, which they feel are caused by ECT-induced brain damage, and methodologic issues with studies supporting the efficacy of ECT. The main problem with their critique is that they appear to misinterpret the statistics they are presenting.

For example, when they discussed the findings of Peltzman and colleagues, they reported that the study found that ECT patients in the Veterans Health Administration (VHA) were 1.3 times more likely to die by suicide than 

 They failed to appreciate that when the authors compared the ECT patients to a risk-matched cohort, this finding did not meet statistical significance (

=.095), despite the large sample size of 14,810 ECT patients and 58,369 controls. They also failed to mention the authors’ conclusion that the “use of ECT in the VHA is rare. Patients who receive ECT have a complex and high-risk profile …”

 Similarly, Hancock and colleagues cite statistics from Duma and colleagues regarding 

 In their meta-analysis of the major cardiac events, the authors conservatively excluded 28 of 82 studies because they reported no adverse events. Without inclusion of this group the incidence of cardiac deaths and all-cause mortality were 0.18 and 0.33 per 1000 patients, respectively. When this group of studies was included, the incidence of cardiac deaths and all-cause mortality dropped to 0.04 and 0.13 per 1000 patients. They also did not consider that in the Veterans Health cohort, the risk ratio of all-cause mortality for the ECT group was a statistically non-significant 0.88, less than the non-ECT group.

My previous response to the question of whether ECT causes brain damage has already highlighted the findings and conclusions of Gbyl and Videbech, who reviewed 32 imaging studies of ECT with a total of 467 patients and 285 controls. They reported that none of the studies they reviewed found evidence of 

 Hancock and colleagues point to EEG, PET, SPECT, and fMRI data that show relative decreases in the activity of the frontal and temporal lobes after ECT as evidence that ECT causes brain damage.

 They do not appear to have considered the data that show depression is associated with overactivity in these same brain regions.

In addition to failing to present a balanced interpretation of the safety data for ECT, Hancock and colleagues ignore converging lines of evidence that support the efficacy of ECT. For example, they reject a study such as that published by Helle and colleagues, for lack of a 

 In this study, the authors used a randomized parallel treatment design with blinded raters to compare brief-pulse RUL to algorithm-based pharmacology in 73 subjects with bipolar depression. They found a significantly higher response rate of 73.9% for the ECT group versus 35.0% for the medication group (

 = .01). These results are remarkably similar to those of Perugi and colleagues, who treated 522 consecutive patients with treatment-resistant bipolar disorder with ECT and found response rates of 68.1 for bipolar depression, 72.9% for mixed state, 75% for mania and 80% for catatonia.

 To provide some context for these response rates, one of the pivotal clinical trials for the olanzapine/fluoxetine combination treatment for bipolar depression reported a response rate of 56.1% for the active drug versus 30.4% for the placebo treatment arm.

 Although these latter results are from a separate study, the response rates are consistent with other medication studies in this population.

Most importantly, we should not forget that the treatment options for individuals afflicted with severe depression, many of whom actively contemplate suicide frequently, are limited. Hancock and colleagues should apply balanced, rigorous scientific scrutiny to the available data before they advocate against ECT. Their analysis to date has not met that standard.

is the head of ECT and lecturer on psychiatry at Massachusetts General Hospital. He receives salary support from a National Institutes of Health grant on ECT.

1. Henry ME. ECT: an effective and safe treatment. 

2. Peltzman T, Gottlieb DJ, Shiner B, Riblet N, Watts BV. Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics. 

3. Peltzman T, Shiner B, Watts BV. Effects of Electroconvulsive Therapy on Short-Term Suicide Mortality in a Risk-Matched Patient Population. 

4. Duma A, Maleczek M, Panjikaran B, Herkner H, Karrison T, Nagele P. Major Adverse Cardiac Events and Mortality Associated with Electroconvulsive Therapy: A Systematic Review and Meta-analysis. 

5. Gbyl K, Videbech P. Electroconvulsive therapy increases brain volume in major depression: a systematic review and meta-analysis. 

6. Fosse R, Read J. Electroconvulsive treatment: hypotheses about mechanisms of action. 

7. Dale E, Pehrson AL, Jeyarajah T, et al. Effects of serotonin in the hippocampus: how SSRIs and multimodal antidepressants might regulate pyramidal cell function. 

8. Schoeyen HK, Kessler U, Andreassen OA, et al. Treatment-resistant bipolar depression: a randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment. 

9. Perugi G, Medda P, Toni C, et al. The role of electroconvulsive therapy (ECT) in bipolar disorder: effectiveness in 522 patients with bipolar depression, mixed-state, mania and catatonic features. 

10. Tohen M, Vieta E, Calabrese J, et al. Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression. 

11. Bahji A, Ermacora D, Stephenson C, et al. Comparative efficacy and tolerability of adjunctive pharmacotherapies for acute bipolar depression: a systematic review and network meta-analysis. 

12. Pompili M, Verzura C, Trovini G, et al. Lurasidone: efficacy and safety in the treatment of psychotic and mood disorders. 

Research data shows that ECT is often more effective than alternative treatments, and safe too. 

In Defense of ECT

 have agreed to continue their debate online. Below, Ms. Hancock, Ms. Cunliffe, and Dr Read argue that ECT is ineffective and unsafe. Representing the pro-ECT position, Dr Henry has responded to their article 

We thank Michael E. Henry, MD, for responding to our article electroconvulsive therapy (ECT): “

,” Henry challenges the conclusion of a recent review

 that there is no robust evidence to determine whether ECT is better than placebo: “The selection criteria used by Read and colleagues were limited to older studies (1956 to 1985).”

 The selection criteria were not time-limited. There simply have not been any placebo-controlled ECT studies since 1985.

 Furthermore the 11 pre-1986 studies were grossly flawed.

We agree with Henry that modern treatment approval requires rigorous, randomized, placebo-controlled methodology using the universally accepted standards of evidence-based medicine. ECT clearly lacks this sort of evidence-base.

Henry produces 3 traditional defences for this empirical data vacuum. First, he argues that studies without placebo control groups, such as comparing different electrode placements, are sufficient. A review of these non-placebo studies, however, revealed that none “produced robust evidence that ECT is effective for depression, primarily because at least 60% maintained ECT participants on medication, 89% produced no meaningful follow-up data beyond the end of treatment, and none investigated whether ECT prevents suicide.”

Second, Henry refers to “more than 75 years of clinical experience”

 as evidence of efficacy. Unfortunately, history is littered with treatments used for decades until deemed ineffective, harmful, or both.

Third, Henry brings up the “ethical dilemma of treating very ill patients with a placebo treatment.”

 But this assumes ECT is safe and more effective than a placebo, and that is precisely what is in question. Assuming its efficacy would position ECT proponents beyond the parameters of evidence-based medicine. Testing treatments in vulnerable populations is essential to establish efficacy, safety limits, and device regulatory protocols.

Henry portrays ECT-induced brain abnormalities, like hippocampal enlargement, as necessarily beneficial. However, a 2013 review of more than 100 imaging studies concluded “the temporarily improved scores on depression instruments following ECT reflect the combination of frontal and temporal lobe functional impairments and activation of the HPA axis and the mesocorticolimbic dopamine system. These effects as well as other detailed changes observed in structures such as the hippocampus appear consistent with those typically seen after severe stress-exposure and/or brain trauma.”

There is no evidence that ECT prevents suicide. A recent study found that 14,810 ECT patients were 1.3 times more likely to die by suicide than 58,369 ECT controls.

1. ECT provides only short-term symptom relief. There are no studies demonstrating ECT outperforms placebo beyond treatment termination, and none that it prevents suicide.

2. Between 12% and 55% of ECT recipients live with persistent memory loss,

 which is suffered disproportionately by women and older individuals, ECT’s target demographic groups.

3. Thymatron ECT device manufacturer lists 7 administration technique variables associated with risks of “

permanent brain damage and permanent memory loss

4. One in 50 ECT recipients suffer “major adverse cardiac events and death after ECT.”

5. Despite repeated requests, the US Food and Drug Administration acknowledges never receiving premarket PMA studies assessing safety or Product Development Protocols to establish 

 ECT research has still not produced any safety testing using modern clinical parameters, dosing limits, or universal administration technique protocols to reduce risks and enable replicable results.

6. Medicare reimburses ECT providers who fail to report quality data, without limits in the number of treatments provided or 

 The 34% increase in US hospitals providing ECT since device reclassification may reflect what happens when hospitals identify an unregulated income source.

7. No one knows how many Americans receive ECT each year, or how many treatments each individual receives, or 

8. ECT recipients are not provided legal informed consent regarding all risks.

9. ECT providers are not routinely assessing each patient for all known risks.

10. Repetitive intracranial mild traumatic brain injury has life-long consequence.

11. ECT recipients injured by treatment are rarely referred for comprehensive rehabilitation to improve quality of life.

12. ECT privileging requirements in the US do not include studying its 

 Without such training, psychiatrists cannot provide appropriate long-term follow-up as recommended by Thymatron device manufacturer.

Failure to acknowledge adverse effects of ECT, with life altering consequences in some patients, creates insurmountable barriers to those injured who need appropriate rehabilitation interventions to improve quality of life after treatment. ECT’s immediate and long-term damage to so many far outweigh its temporary benefits for some individuals.

 is a nationally certified rehabilitation counselor and former Clinical Rehabilitation Counseling and Clinical Mental Health faculty member at San Diego State University. More than a decade ago, Sarah received 116 ECT treatments and now lives with long-term neurological sequalae of repeated exposure to high electrical fields.

is professor of clinical psychology at the University of East London. He is chair of the International Institute for Psychiatric Drug Withdrawal and editor of the scientific journal 

. He has authored several books and more than 200 research papers.

was a pediatrician in the UK until she left her job after undergoing ECT. She has become an advocate for other ECT patients. 

. 2021;38(4):4,7. Accessed April 16, 2021.

2. Read J, Hancock S, Cunliffe S, Henry ME. ECT: dangerous on either side of the pond. 

. 2021;38(4):4-6. Accessed April 16, 2021. 

3. Read J, Kirsch I, McGrath L. Electroconvulsive therapy for depression: a review of the quality of ECT versus sham ECT trials and meta-analyses. 

4. Gregory S, Shawcross CR, Gill D. The Nottingham ECT Study. A double-blind comparison of bilateral, unilateral and simulated ECT in depressive illness. 

5. Read J, Arnold C. Is electroconvulsive therapy for depression more effective than placebo? A systematic review of studies since 2009. 

7. Peltzman T, Gottlieb DJ, Shiner B, et al. Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics. 

Regulatory Update to Thymatron System IV Instruction Manual

. Somatics, LLC; 2018. Accessed May 6, 2021. 

9. Duma A, Maleczek M, Panjikaran B, et al. Major adverse cardiac events and mortality associated with Electroconvulsive Therapy: A Systematic Review and Meta-analysis. 

10. Food and Drug Administration. Reclassification of electroconvulsive therapy devices; effective date of requirement for premarket approval for electroconvulsive therapy devices for certain specified intended uses. Published online December 26, 2018. Accessed May 6, 2021. 

11. Centers for Medicare & Medicaid Services. Medicare program: fiscal year 2021 inpatient psychiatric facilities prospective payment system and special requirements for psychiatric hospitals for fiscal year beginning October 1, 2020. 42 CFR Parts 412 and 482. 2020;16990. 

12. Hancock SP. Whose finger is taking the pulse of America’s shock treatment controversy? Mad In America. July 16, 2020. Accessed May 6, 2021. 

13. American Psychiatric Association Committee on Electroconvulsive Therapy. 

The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association. 2nd ed.

 American Psychiatric Association; 2001. Accessed May 5, 2021. 

ECT has been in use for decades, but does that mean it is safe or effective? 

Raising Doubts About ECT

Dr Komrad has made a video to accompany this article. You can watch the video 

Currently, several countries, such as Belgium, the Netherlands, Luxembourg, and Switzerland, allow patients who are suicidal to receive death by either lethal injection (euthanasia) or a self-administered prescription for lethal medication (assisted suicide). In 2002 Belgium, the Netherlands, and Luxembourg (all 3 collectively known as 

) legalized both these practices. Laws in those countries permitted voluntary death for patients whose physical or psychological suffering was unbearable and could not be effectively treated by means that were 

 A terminal condition was not a necessary criterion.

This opened the door for some patients with psychiatric illness to have suicide provided for them, rather than prevented. Now between 100 and 200 patients with psychiatric illness are euthanized upon request annually between 

These laws are being passed around the world, and they could profoundly change the practice of psychiatry. In concerned response to those developments, the American Psychiatric Association issued a 

 in 2016: “A psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”

 Psychiatrists traditionally have done all they could to prevent suicide. Should they really facilitate it instead?

Canada is the latest nation to legalize voluntary death for psychiatric conditions. In 2016, Canada passed Bill C-14, a law permitting medical euthanasia and physician-assisted suicide, together known as medical aid in dying (

 By November 2020, more than 19,000 individuals nearing the end of life had been voluntarily 

A key eligibility criterion of this law was that a patient’s natural death is predicted to be 

a unique Canadian terminology that was not statutorily defined. Although it was associated with the end of life, how close was never decided. Because death from mental disorders was not seen as strongly predictable, mental illnesses were not considered eligible conditions. This feature of the law was a check on the kind of psychiatric euthanasia practiced in the Benelux countries.

In 2019, however, a Quebec Superior Court ruling challenged the constitutionality of restricting the C-14 right of euthanasia to those whose death is reasonably 

 As a result, a new federal bill was introduced to extend euthanasia eligibility, without limiting it to the end of life. This new initiative, Bill C-7, followed the Benelux model; it and removed the prior exclusion of those who have non-terminal chronic illnesses and permitted euthanasia for those whose psychological or physical suffering is deemed intolerable and 

Initially, Bill C-7 clearly excluded psychiatric disorders, as it did in the original C-14 law. However, there was ambiguity in this proscription, because psychological suffering (which is not defined in either legislation) continued to be a criterion for eligibility. In addition, many protested that such an exclusion discriminated against those with mental illnesses. The Canadian Psychiatric Association (CPA) was 

, declaring broadly that, in the interest of parity: “Patients with a psychiatric illness should not be discriminated against solely on the basis of their disability, and should have available the same options regarding MAID as available to all patients.”

This led to a dramatic turn of events in the (unelected) Canadian Senate when it considered Bill C-7 in February 2021. In an unprecedented move, Senator Stan Kutcher, MD, who is also a psychiatrist, declared that the exclusion of individuals with psychiatric disabilities would be discriminatory. He introduced an amendment that would allow MAID for mental illness 18 months following the 

 When the modified legislation was returned to the House of Commons, discussions were shut down after 3 hours by a liberal coalition and the bloc party from Quebec (a province that has promoted euthanasia and aimed to restrict conscientious objection to euthanasia by health care professionals). As a result, the vote was forced and, on March 17, 2021, the C-7 expansion of euthanasia in Canada became the law of the land complete with a last-minute amendment to sunset the mental illness exclusion 

In this interval, an expert panel will establish standards for evaluating patients and procedures to distinguish between those patients with psychiatric disorders whose suicide should be prevented and those for whom it should be provided. Nonetheless, as the Euthanasia Prevention Coalition’s executive director, Alex Schadenberg, observed in response to a query, “there isn’t a prosecutor in the land who would prosecute someone for doing euthanasia for mental illness before the 24-month time frame has passed because it is technically legal.”

Objections to Psychiatrist-Assisted Suicide

This is a profound change in the trajectory of the euthanasia law, and the practice of psychiatry for Canada, which is now the largest nation that will soon allow MAID for psychiatric conditions. It has rocked the professional mental health community in Canada who fought to forestall the inclusion of psychiatric disorders for euthanasia. Once these procedures were deemed medical procedures, distinguishing eligible patients would be challenging, if not impossible.

Countries that have allowed MAID in a limited number of cases have quickly found themselves descending a slippery slope. Wesley J. Smith, JD, prominent critic of these policies, 

: “Once a society embraces doctor prescribed death as an acceptable answer to human suffering or as some kind of fundamental liberty right, there are no brakes. We need only look at European countries that have gone down the Euthanasia Highway to see how society is impacted deleteriously by accepting killing as a suitable answer to the problem of human suffering.”

 Indeed, in Belgium and the Netherlands policy makers and legislators are debating extending euthanasia beyond medical conditions to include those who feel they have a completed life

 There even is a discussion of demedicalizing euthanasia by providing lethal pills over the 

 Pegasos, a Swiss voluntary assisted dying association based in Basel, currently provides euthanasia for nonmedical suicide 

Many psychiatrists in Canada are deeply concerned by the recent developments. In the face of Bill C-7, the psychiatrist editor of the 

A few days ago, a 30-year-old patient with very treatable mental illness asked me to end her life. Her distraught parents came to the appointment with her because they were afraid that I might support her request and that they would be helpless to do anything about it. It’s horrific they have to worry that by going to a psychiatrist, their daughter might be killed by that very psychiatrist.

The disability advocacy community has objected to the way that Bill C-7 untethers MAID from the 

 They are concerned that allowing non-terminal, disabled individuals euthanasia implies that their lives may be not worth living. Furthermore, they recognize individuals with disabilities may not have adequate access to state-of-the-art treatment, and euthanasia could become a cost-saving alternative to suffering when adequate solutions are not available or affordable.

An evaluation by the United Nations expressed strong worry about how Bill C-7 impacts individuals with 

We are deeply concerned that the eligibility criteria set out in Bill C-7 to access medical assistance in dying may be of a discriminatory nature, or have a discriminatory impact. By singling out the suffering associated with disabilities being of a different quality and kind than any other suffering, they potentially subject persons with disability to discrimination on account of such a disability.

There is also strong objection among many First Peoples of Canada because of conflicts with their cultural values, their limited access to state-of-the-art treatments, and 

 The Canadian Catholic Bishops, who always oppose euthanasia, are particularly aghast at allowing MAID for 

Bill C-7 also sets up a 2-tier system, abolishing some of the original Bill C-14 safeguards. For instance, patients who are terminally ill can be evaluated for euthanasia and possibly receive it on the same day, with no waiting period; unlike the 10-day waiting period in the previous C-14 law. However, patients who are not terminally ill must wait 90 days. Unfortunately, it is not unusual to wait much longer than 90 days to receive psychiatric consultation, treatment, and other resources.

Moreover, as with C-14, there is no requirement that additional, evidenced-based treatments be implemented, although patients are urged to give all treatments serious consideration Yet, despite its liberal approach, Belgium recently established a requirement that individuals applying for euthanasia due to a mental disorder must not have refused any evidenced-based treatments.

A group of experts in Canadian law and medicine 

C-7 will allow physicians to end the life of people with disabilities or chronic illnesses at their request and will require the system to ensure it happens even when physicians are convinced, based on their expert knowledge, that medicine offers options and even when the patient may have years or decades to live with a good quality of life if other options are explored and tried first.

The American Medical Association has repeatedly 

that MAID practices are “fundamentally incompatible with the physician’s role as a healer,”

 “is firmly opposed to euthanasia and assisted suicide.”

 Nevertheless, these laws have been adopted around the world, most recently in Victoria Australia, New Zealand, Spain, and 

 In US states, there have been attempts to expand initially strict criteria and 

 The justifications for euthanasia and assisted suicide (eg, autonomy, self-determination, intolerable suffering, and irremediability) are now being applied to psychiatric disorders, despite lack of any widespread agreement that treatments for psychiatric disorders are ever futile.

Bill C-7 and similar laws would represent a terrible shift in the deep ethos of psychiatry. Psychiatrists would have to decide which suicides should be prevented and which should be abetted. Karandeep Sonu Gaind, MD, past president of the CPA and a fierce critic of this bill, noted the less-privileged have a much harder time accessing medical care in general, especially psychiatric treatment. He lamented the passing of C-7 in a poetic 

Will reflect the privilege of our life trappings.

I will soon be free, without anxiety, knowing

That with ease I can choose the time of my going.

And any poor souls sacrificed on this altar

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland, clinical assistant professor of Psychiatry at the University of Maryland, and Teaching Faculty of Psychiatry at Tulane University in New Orleans

1. Komrad M. A psychiatrist visits Belgium: the epicenter of psychiatric euthanasia. 

. June 20, 2018. Accessed April 28, 2021. 

2. Du Bus C. Euthanasia in Belgium: analysis of the 2020 Commission Report. European Institute of Bioethics. November 16, 2020. Accessed April 28, 2021. 

3. Regional Euthanasia Review Committees. Annual Report 2019. April 2020. Accessed April 28, 2021. 

4. Komrad M. APA position on medical euthanasia. 

5. Komrad M. Medical euthanasia in Canada: current issues and potential future expansion. 

. June 29, 2018. Accessed April 28, 2021. 

6. Schadenberg A. There have been approximately 19,000 euthanasia deaths in Canada. Euthanasia Prevention Coalition. October 20, 2020. Accessed April 28, 2021. 

7. Marin S. Quebec court invalidates parts of medical aid in dying laws as too restrictive. 

. September 11, 2019. Accessed April 28, 2021.

8. Bill C-7: an act to amend the criminal code (medical assistance in dying). 1st reading February 24, 2021, 43rd Parliament, 1st session. Accessed April 28, 2021. 

9. Chaimowitz G, Freeland A, Neilson GE, et al. Medical assistance in dying. Canadian Psychiatric Association. February 10, 2020. Accessed April 28, 2021. 

10. Bryden J. Senators amend MAID bill to put 18-month time limit on mental illness exclusion. 

 February 9, 2021. Accessed April 28, 2021. 

11. Bryden J. Canadian Senate passes Bill C-7, expanding assisted dying to include mental illness. 

. Updated March 19, 2021. Accessed April 28, 2021. 

12. Smith W. Euthanasia spreads in Europe: many nations find themselves far down the slippery slope. 

. October 26, 2011. Accessed April 28, 2021. https://www.nationalreview.com/2011/10/euthanasia-spreads-europe-wesley-j-smith/

13. Boztas S. Euthanasia law proposed for healthy over-75s who feel their lives are complete. 

. July 19, 2020. Accessed April 28, 2021.

14. Cohen-Almagor R. Euthanizing People Who Are “Tired of Life.” In: Jones DA, Gastmans C, MacKellar C, eds. 

Euthanasia and Assisted Suicide: Lesson from Belgium

. Cambridge University Press; 2017:188-201.

15. Clusky P. Euthanasia debate in Netherlands takes an unwelcome twist. 

. September 10, 2019. Accessed April 28, 2021.

16. Cook M. A new Swiss group caters for Dutch who are eligible for euthanasia. 

. January 24, 2021. Accessed April 28, 2021.

17. Maher J. Why legalizing medically assisted dying for people with mental illness is misguided. 

. February 11, 2020. Accessed April 28, 2021. 

18. Neves P. Disability is not a fate worse than death. 

. Updated March 27, 2021. Accessed April 28, 2021. 

19. Quinn G, Mahler C, De Schutter O. Mandates of the Special Rapporteur on the rights of persons with disabilities; the Independent Expert on the enjoyment of all human rights by older persons; and the Special Rapporteur on extreme poverty and human rights. February 3, 2021. Accessed April 28, 2021. 

20. Ruck A. First nations leaders say Bill C7 goes against their beliefs and values. 

. February 12, 2021. Accessed April 28, 2021. 

Will a new Canadian law overturn long-held ethical norms in psychiatry? 

Depression

New Directions in Addressing Motivational Deficits in Schizophrenia and Depression

A Spirited Defense of ECT: From Our Readers

In Defense of ECT

Raising Doubts About ECT

Oh, Canada! Your New Law Will Provide, Not Prevent, Suicide for Some Psychiatric Patients

Dreaming of New Treatments

6 Lessons From a Tragedy

Making Their Own Mistakes

Psychiatry and the Long View: Paul Summergrad, MD

Anger and Its Causes