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In Belgium, the Netherlands, and Luxemburg over a hundred psychiatric patients a year receive medical aid in dying (MAID). They do not need to have a terminal condition, only a degree of suffering that they find intolerable. This could include mental suffering, brought on, for instance, by depression.

MAID laws are now passing in the United States, and psychiatrists may soon face a difficult question. Should they help patients, who say their psychiatric conditions are unbearable, end their lives? In this Mental Health Minute, Mark S. Komrad, MD, discusses the various forms of MAID and makes a case against them, especially for psychiatric patients.

Read Komrad’s full feature article on MAID 

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.

Should psychiatrists ever assist in suicide? 

Share comments with your colleagues by emailing 

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

Medical aid in dying is available for psychiatric patients in European countries and Canada. Will the United States be next? 

Are Psychiatrists who Assist in Suicide Betraying Their Professional Values?

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. 

21. Ruck A. Canadian Conference of Catholic Bishops denounces assisted suicide law. 

22. Verhofstadt M, Van Assche K, Sterckx S, et al. Psychiatric patients requesting euthanasia: Guidelines for sound clinical and ethical decision making. 

23. Lemmens T, Shariff M, Herx L. How Bill C-7 will sacrifice the medical profession’s standard of care. 

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

24. Euthanasia. Code of medical ethics opinion 5.8. American Medical Association. Accessed April 28, 2021. 

25. World Medical Association. WMA declaration on euthanasia and physician-assisted suicide. October, 2019. Accessed April 28, 2021. 

26. Euthanasia and physician-assisted suicide (PAS) around the world: legal status in 28 countries from Australia to Uruguay. ProCon.org. Updated December 3, 2020. Accessed May 10, 2021. 

27. Schadenberg A. Washington State debates bill to expand assisted suicide law. Say no to same day death. Euthanasia Prevention Coalition. January 11, 2021. Accessed April 28, 2021. 

28. Gaind KS. What Does "Irremediability" in Mental Illness Mean? 

29. Gaind KS. Last rights. March 11, 2021. Accessed April 28, 2021. 

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

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

Changing a single ingredient in the diet rarely makes a difference in studies of depression. 

, soy, and matcha tea have all been tried without success.

 Instead, nutritional psychiatry research has 

 the best antidepressant effects with a balanced, Mediterranean-style diet.

 But a small trial of almond supplementation in diabetes shows promise.

The study was a small, randomized controlled 

 of 45 Chinese adults with type-II diabetes.

 All of the subjects were counseled to adopt a low-fat diet that was rich in vegetables and protein and low in salt and carbohydrates. The control group was allowed a daily serving (300 grams) of a carbohydrate-rich food (in China, this was typically rice or noodles), while the intervention group cut that carb dish in half and replaced it with 56 grams of almonds (about half a cup).

After 3 months, those in the almond group had a significant reduction in depression on the self-reported PROMIS scale, while the average mood of the control group did not budge. The effect size was large (0.94 using Hedges’ correction for small sample sizes), although the statistical spread on that effect was wide (+/- 0.62). Importantly, the investigators did not require a diagnosis of depression to enter the trial. On average, their scores (49) fell just below the 55-point cut-off for mild depression on the 

, although some had moderate or severe depression (up to 81 on the PROMIS).

Metabolic parameters (weight and glycated hemoglobin (HbA1c)) improved significantly with both diets, although the reduction in HbA1c was larger (by 1 point) in the almond group (p < 0.01). Next, the investigators looked at changes in the gut microbiome to clarify the mechanism behind this antidepressant effect.

A diverse microbiome in the GI tract is associated with both metabolic and mental health. The gut bacteria 

 with the brain through multiple pathways, including the vagus nerve, inflammatory signaling, and short-chain fatty acids.

 microbiome diversity improved in both groups, but the almond group had a significant increase in bacterial species that produce short chain fatty acids (

). This type of bacteria stimulates production of the metabolic hormone glucagon-like peptide-1, which lowers appetite and regulates insulin. Supporting this hypothesis, levels of glucagon-like peptide-1 rose throughout the trial in the almond group.

is the Mood Disorders Section Editor for 

 He has written several books on mood disorders, most recently 

 with his co-host Kellie Newsome, PMH-NP.

The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for 

Effects of walnut consumption on mood in young adults-a randomized controlled trial.

2. Simpson EEA, Furlong ON, Parr HJ, et al. 

The effect of a randomized 12-week soy drink intervention on everyday mood in postmenopausal women.

3. Dietz C, Dekker M, Piqueras-Fiszman B. 

An intervention study on the effect of matcha tea, in drink and snack bar formats, on mood and cognitive performance

A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial).

An almond-based low carbohydrate diet improves depression and glycometabolism in patients with type 2 diabetes through modulating gut microbiota and glp-1: a randomized controlled trial.

Minimally important differences and severity thresholds are estimated for the PROMIS depression scales from three randomized clinical trials

7. Bastiaanssen TFS, Cowan CSM, Claesson MJ, Dinan TG, Cryan JF. 

Making sense of … the microbiome in psychiatry.

Subba R, Sandhir R, Singh SP, Mallick BN, Mondal AC. 

Pathophysiology linking depression and type 2 diabetes: Psychotherapy, physical exercise, and fecal microbiome transplantation as damage control.

Qian F, Liu G, Hu FB, Bhupathiraju SN, Sun Q. 

Association between plant-based dietary patterns and risk of type 2 diabetes: a systematic review and meta-analysis

Francis HM, Stevenson RJ, Chambers JR, Gupta D, Newey B, Lim CK. 

A brief diet intervention can reduce symptoms of depression in young adults - A randomised controlled trial.

Parletta N, Zarnowiecki D, Cho J, et al. 

A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: A randomized controlled trial (HELFIMED).

Sánchez-Villegas A, Martínez-González MA, Estruch R, et al. 

Mediterranean dietary pattern and depression: the PREDIMED randomized trial.

A daily serving of almonds improved depressive symptoms in diabetes, but will it work in non-diabetic depression?

Almonds May Lift Depression in Diabetes

LGBTQ COMMITTEE OF THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

As the number of COVID-19 cases in the United States hits 30 million and continues to cause widespread pain in lives lost and economic devastation, sexual and gender minority youth face particular hardships threatening their lives, mental health, and social development.

In particular, social isolation may be especially challenging. These youths may be quarantining with rejecting family-members and losing contact with supportive social networks. The nature of quarantining means these problems are invisible to the public.

“Aiden,” a 16-year-old boy who is transgender, lives in a community particularly hard-hit by COVID-19. Aiden’s parents refuse to accept his gender identity or call him by his male name or use male pronouns. They frequently yell at Aiden to dress and act like a girl, assigning dishwashing and laundry chores to him alone, and not to his brother, to get him “used to doing girl stuff like you are supposed to.”

Serial COVID-19 outbreaks at Aiden’s school forced him into remote learning. His family has only 1 computer, shared by Aiden and his brother for schoolwork and Aiden’s mother for church meetings. Aiden’s parents banned him from using social media or communicating with friends because his parents believe “that’s where she picked up all this nonsense.” Aiden became completely disconnected from his friends. He was also cut off from affirming and supportive teachers. As tensions in Aiden’s family escalated, fighting became the only interaction between him and his parents.

One evening during a fierce argument, Aiden’s mother pushed him, and he pushed her back. As a result, she fell and had a small laceration on her shoulder. Aiden’s father became angry and punched Aiden in the face. Aiden’s brother called 911. The police arrested Aiden and his father. Aiden was released from jail to a Child Protective Services emergency residence. Because of COVID-19, he was required to spend 14 days isolated in his room, including mealtimes, and was unable to receive visitors. He also faced misdemeanor charges for assaulting his mother. His father also faced charges. Aiden was afraid of returning home because he was petrified of what his father might do to him.

Administration for Children’s Services (ACS) attempted to reunify Aiden with his parents, but over a period of several months, each attempt resulted in further physical altercations between Aiden and his father. Aiden moved into a group home where peers bullied him because of his gender identity. ACS was unable to address the problem because several staff members were hospitalized with COVID-19, and no other group homes were available for transfer. After a bully hit him, Aiden ran away from the group home, and the police could not locate him.

Even before COVID-19, lesbian, gay, bisexual, transgender, questioning (LGBTQ) youth were at 

 of depression, suicidality, and tobacco, alcohol, and other drug use.

 These increased risks stem from elevated rates of rejection, discrimination, and victimization. During the pandemic, risks were further compounded by the loss of relationships in schools, clubs, or other community venues where LGBTQ youth found support and affirmation. Laura Erickson-Schroth, MD, a psychiatrist at the Hetrick-Martin Institute, a New York City-based LGBTQ youth organization, reported that youth members of the institute are looking for more frequent counseling sessions. According to her, there were at least one-third more requests for initial psychiatry visits during 2020 than during the same period in 2019.

 found one-third of the city’s youth in foster care identifies as LGBTQ, an order of magnitude greater than the general population.

 Nearly three-quarters of these youth are Black, and one-third identify as Hispanic/Latino. LGBTQ youth are placed in group homes and other campus settings rather than foster families more often than their non-LGBTQ peers, and they are more likely to be dissatisfied with their placement. The study also found these youth experience a greater burden of depression.

According to Dylan Waguespack, director of public policy and external affairs of 

, 20% to 40% of homeless youth identify as LGBTQ. True Colors United is a national organization dedicated to ending LGBTQ youth homelessness. Although family conflict, involvement in the foster care system, and involvement in the criminal justice system are among the factors that contribute to homelessness among these youth, poverty is often the root cause. Not only are these youth at risk for adverse mental health outcomes because of rejection and discriminatory behaviors, they often face traumatic experiences through conflict with their families, involvement in overwhelmed and poorly informed state programs.

Agencies that previously made efforts to address racial, social, gender, or sexuality based inequities before the pandemic have become even more overwhelmed with the increase in housing and food insecurity, increased unemployment, instability in the agency’s own staff, and the need to rapidly implement physical distancing and other public health measures in routine work. Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications.

Even as the pandemic ends, there may be continual struggles and support needs. Fortunately, there are ways psychiatrists and other mental health care professions can help.

Some of these methods include the following:

Financially donate to organizations that support or serve LGBTQ youth.

Advocate for programs that decrease income inequality and promote housing and food security.

Enable rapid interventions to prevent LGBTQ youth from entering the foster care and criminal justice systems.

Use clinical, teaching, institutional, and forensic roles to speak out and advocate for this vulnerable group of young people.

Share resources and references for supportive organizations with patients who are LGBTQ (

LGBTQ youth have long experienced marginalization and significantly increased risk of poor mental health outcomes. The COVID-19 pandemic sharpened the crisis and brought clarity to the precariousness of social service agencies that address those needs. Strengthening the support system for these youth and their allies and making agencies more inclusive of their voices is critical to help these young people achieve a healthy and fulfilling life.

is the director of the Youth Equity Science/YES Project and senior visiting fellow at Yale Law School. He is also an assistant clinical professor at Columbia University and an adjunct clinical assistant professor at Cornell Weill Medical College.

the medical director emeritus at Weill Cornell Center for Human Rights. Dr Barberis the past president and journal editor for the Association of LGBTQ Psychiatrists and is an MDiv candidate at Union Theological Seminary.

is a community and public psychiatrist in New York City.Dr Drescher is a clinical professor of psychiatry at Columbia University and an adjunct professor at New York University. He is also a distinguished life fellow of the American Psychological Association and the past president of the Group for Advancement of Psychiatry

is an assistant professor of psychiatry at Columbia University Medical Center and a consulting psychiatrist at Hetrick-Martin Institute for LGBTQ youth.

. 2020;18(3):268-276. doi:10.1176.appi.focus.20200018
2. Sandfort TGM. Experiences and well-being of sexual and gender diverse youth in foster care in New York City: disproportionality and disparities. November 2020. Accessed January 5, 2020. 

https://www1.nyc.gov/assets/acs/pdf/about/2020/WellBeingStudyLGBTQ.pdf

Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications. There are 5 ways psychiatrists can help.

Helping LGBTQ Youth During the Pandemic

Psychiatry may be lagging behind other branches of medicine in an important way.

“In the rest of medicine, as you increase the acuity you increase the number of treatments,” Nolan Williams, MD, told the attendees of the 2021 American Psychiatric Association (APA) Annual Meeting, but in psychiatry, “as we increase acuity we actually lose treatment options.”

Williams and his fellow presenters at a panel on rapidly acting medications

 all had the same question: How can psychiatrists design treatments to respond to sudden-onset conditions?

Williams, assistant professor of psychiatry and behavioral sciences at Stanford University Medical Center, described the situation as “emergency room purgatory.” Because of slow-acting treatments and limited hospital capacity, “the whole process of going through the inpatient unit can take several months,” he said. “The only treatment that we have available for these folks is ECT [electroconvulsive therapy.” But ECT is available in only 10% of US hospitals.

However, psychiatrists might have other options for fast-acting treatments. He shared 

showing that accelerated theta burst repetitive transcranial magnetic stimulation (r-TMS) had positive results for mood disorders, including MDD.

 R-TMS treatment works by stimulating the left dorsolateral prefrontal cortex (DLPFC). In MDD, the DLPFC may be failing to inhibit the subgenual cingulate, and the result of this network failure is cognitive impairment and inwardly directed negative thoughts,” Nolan explained. “By stimulating DLPFC, r-TMS corrects the mood imbalance and restores mood regulation.”

In initial numbers from his study of patients with a treatment-resistant mood disorder (TRD), Nolan found that after 5 days of sessions (10 hourly sessions at 1800 theta-burst pulses per hour), participants improved. On the Montgomery Asberg Depression Rating Scale (MADRS), he found an 80% average reduction of participants MADRS scores.

Another options for fast-acting treatment is ketamine. Charles DeBattista, MD, professor of psychiatry and behavioral sciences at Stanford University, presented evidence for its efficacy for TRD. He noted that ketamine is an anesthetic agent, a μ-opioid agonist, and while its effects on TRD are rapid, making it potentially helpful in psychiatric emergencies. “Often within a couple of hours to a day, patients experience a significant improvement, and the effects were sustained for a week or so,” he said. These effects did decrease after a week, but there is also evidence that repeated injections may lead to 

DeBattista also presented the option of esketamine, which has been fast tracked by the US Food and Drug Administration for treating TRD and acute suicidality in MDD. Multiple studies have found that it rapidly 

New mothers represent another population that might benefit from fast-acting medications. “Maternal mental health is something that’s been an enormous problem forever,” said Samantha Meltzer-Brody, MD, MPH. “Those of us that have the privilege of working with perinatal women are always struck by how debilitating PPD [postpartum depression] can be.” Rapidly acting medications could reduce mortality and morbidity, she said, and allow for more positive interactions between mothers and their newborns.

Although many selective serotonin reuptake inhibitors are approved to treat PPD, she pointed out that their initial effects may not be felt for weeks or even months, and many women’s symptoms do not respond to them. Meltzer-Brody, the Assad Meymandi Distinguished Professor and Chair in the University of North Carolina Department of Psychiatry, also considers an alternative to these medications: neurosteroids like brexanolone.

In a 2018 paper, Meltzer-Brody and her coauthors found brexanolone to be effective for

 Using the HDRS for measurement, the researchers found an average 8- to 10-point reduction in 12 hours, and around an 18-point reduction at 60 hours, the study’s primary endpoint. At day 30, participants average reduction remained, on average, 16 points down from baseline. The paper hypothesized that brexanolone works by increasing γ-aminobutyric acid (GABA) function, which appears to be inhibited during PPD.

With these new options, it seems psychiatry may not lag behind other branches of medicine for long. 

1. Williams N. Developing rapidly acting antidepressants: neurosteroids, dissociative agents (Ketamine Analogues and Psilocybin), and Accelerated Theta Burst r-TMS. Paper presented at: American Psychiatric Association Annual Meeting; May 1-3, 2021; virtual.

2. Nettekoven C, Volz LJ, Kutscha M, et al. Dose-dependent effects of theta burst rTMS on cortical excitability and resting-state connectivity of the human motor system. 

3. Li CT, Chen MH, Juan CH, et al. Efficacy of prefrontal theta-burst stimulation in refractory depression: a randomized sham-controlled study. 

What treatments could handle both psychiatric emergencies and long-standings mental health conditions—in a hurry?  

Major Depressive Disorder

Are Psychiatrists who Assist in Suicide Betraying Their Professional Values?

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

Almonds May Lift Depression in Diabetes

Helping LGBTQ Youth During the Pandemic

Fast-Acting Options for Mood Disorders and Psychiatric Emergencies

Depression: A Family Affair

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