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In this Mental Health Minute, Jasmin Zapata, MD, discusses young women’s mental health and encourages clinicians to engage with the community—outside of medical settings—to promote good mental health.

books, a series offering mental health guidance to young women and girls.

How do you support young women’s mental health? 

Share comments with your colleagues by emailing 

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

Health outcomes are often determined by factors outside of the hospital and clinic. How can psychiatrists address mental health challenges before they become emergencies?  

Is it Time to Leave the Doctor’s Office? 

June is Posttraumatic Stress Disorder (PTSD) Awareness Month. One psychiatrist is dedicating a portion of the proceeds from his new book, 

 program—in the hopes of curbing US military veteran suicides.

, Norman E. Rosenthal, MD. Dr Rosenthal is a world-renowned psychiatrist and researcher, most widely known for defining seasonal affective disorder (SAD) and pioneering the use of light therapy as treatment.

Psychiatric Times (PT): Tell us about your book Poetry Rx

and what inspired you to address PTSD in veterans in this way.

 Over my years as a psychiatrist and long-time poetry lover, it has become increasingly clear to me that poems can heal, inspire, and bring joy to our lives. Some time ago it occurred to me that this is our goal as psychotherapists, doctors, and healers. Over time I accumulated many poems that have this potential. Finally, I felt I had a way of organizing these poems so that they could deliver on the therapeutic promise of poetry.

PT: Your book features a poem by Russian poet Anna Akhmatova. Why did you choose this particular piece? How does is speak to the overall meaning of your work? Is there a particular poem that stands out to you as the most important?

 I first encountered this poem in the web-based Favorite Poem Project, a brainchild of former poet laureate Robert Pinsky. 

 by Anna Akhmatova was chosen by Georgia Tech professor of cognitive science, Nancy Nersessian, PhD, in memory of her brother, who was a Vietnam veteran traumatized by his wartime experiences. The second stanza of Akhmatova’s poem goes as follows:

Dr Nersessian, whom I interviewed for the book, wondered whether it would have been helpful to her brother to kill the memories of the war that haunted him. In Akhmatova’s poem, we see that this was not a helpful strategy for her. As I discuss after presenting the poem, the intrusive memories of PTSD are often treated by encouraging those who suffer to actively think about their traumatic memories in ways that decondition their painful responses.

In “The Sentence” we also see an excellent depiction of dissociation, which is valuable for individuals suffering from PTSD to understand. It is easier for clinicians to focus on the dramatic symptoms of PTSD like nightmares and flashbacks and to overlook the emotional costs of shutting down one’s emotional dealings with others, which can severely impoverish the life of the individual with PTSD.

Another poem in the book also highlights the problem of PTSD: 

 by Gwendolyn Brooks, in which the poet describes 7 young men in a pool hall. Brooks describes them as lurking late and thinning gin, amongst other behaviors that suggest young men looking for trouble. The last line of this short verse packs a powerful punch: “We die soon.” That poem was brought to my attention by John, a young man in Boston, who was suffering from PTSD after hearing about a violent attack on a close relative. To numb the painful symptoms of PTSD, John started drinking too much, taking substances, and filling his hours with fantasies of revenge. An English teacher saw he was having problems and suggested he try reading and writing poetry. John came across “We real cool” and was impressed by how it described the rapid cascade by which young men can fall into trouble and end up dead. He is now in recovery and credits poetry in general, and “We real cool” in particular, with saving his life.

PT: What impact do you believe poetry has on mental health?

 Mental health involves having the skills to navigate all phases of life. 

 is organized into categories that engage different challenges that we encounter along life’s hopefully long journey. From loving and losing (the first section), to aging and dying (the fifth and last section), the book provides poems that offer specific comfort and advice at all stages. In between these 2 bookends are 3 other sections: 1. Responses to nature; 2. Aspects of the human experience; and 3. A design for living and the search for meaning. After each poem I provide a short essay, which basically discusses what the poem is all about, followed by several specific take-away lessons, ending with a short bio sketch of the poet that illustrates the connection between poet and poem. Individually, the poems offer specific guidelines on specific issues. Collectively, the anthology provides a guide to living a good life and enjoying poetry along the way.

PT: Is creative writing an outlet for you? How has it personally helped your mental health?

 Creative writing has been terribly important to me. There is great joy in being able to say things in exactly the way you want to and have it come out as beautifully as possible. An even greater joy is to touch the reader in a meaningful way by offering descriptions, ideas, and insights that stimulate, comfort, enlighten, delight, or all of the above. I get pleasure and fulfillment in writing and in the response of my readers. During the pandemic when there was so much isolation and deprivation, not to mention fear and loss, the poems themselves and writing about them were a great boon. Here is how I describe the effects they had on me in the closing remarks of my book:

As I think about the poems in this book, what I have learned from them, and how they might help people, certain images come to mind. At times the poems have seemed to me like precious stones, refracting the ambient light and filling the room with color. At other times, they have been like lamps, illuminating the dark caverns of the mind, revealing new ways to understand old mysteries. Beyond these images of delight, however, the poems have felt like medicine or balm, and their poets like healers, speaking to us across the ages. It has been an honor to interpret these great works through the lens of one who has spent my career trying to understand and heal the troubled mind, and help people reach the outer bounds of their potential. I believe that these poems have the power to heal, transform and enliven. Perhaps some of them have done so to you. If not, I hope they have at least offered a brief reprieve from an all-too-often troubled world.

PT: A percentage of proceeds of your book go to the David Lynch Foundation’s Resilient Warrior program.

Can you tell us about the program and what it means to you?

 The David Lynch Foundation is devoted to teaching Transcendental Meditation (TM) to groups of individuals who cannot afford to pay for their own tuition. One such target group consists of veterans with PTSD, of whom an estimated 21 commit suicide every day. Even those who do not meet such a tragic end nevertheless suffer badly.

At one point in my career, when I was CEO of a clinical trials organization, I used a small grant to do a pilot study on the effects of TM on veterans with PTSD and was impressed at the powerful benefits they experienced. Later, I collaborated on a large (210 subject) controlled study of veterans at the San Diego VA, which found that TM was as effective as a standard therapeutic treatment and superior to an active control. These experiences have led me to believe that providing free TM tuition to veterans with PTSD is an excellent way for me to allocate the funds I set aside for charitable donations.

PT: You’re known for your work on the development of light therapy for seasonal affective disorder (SAD). Do you consider yourself more research-oriented or creative-minded?

That seems to me like a misleading dichotomy. I think that a good researcher must be creative-minded, has to put together unexpected pieces of data, chase up hypotheses that seem most likely to yield fruit, assemble a team creatively, and analyze the data creatively. In other words, the best research involves a great deal of creativity at multiple levels. But not all creativity uses the scientific method. Literature, music, and art are creative without using formal scientific methods, such as controlled studies. I always remind myself that our research on SAD began with 1 patient who reported seasonal variations in depression that he hypothesized were driven by changes in environmental light. That led me to think of my own winter lows after immigrating to North America, which I had never suffered in South Africa, my sun-filled native country. We did not leave matters at the anecdotal level, however, and went on to do the scientific work necessary to defining the syndrome of SAD and exploring the beneficial effects of light therapy in its treatment. We collected a large number of individuals who complained of winter depressions, defined the syndrome of SAD, and designed controlled light therapy and other studies exploring which aspects of light therapy were important and how bright light affected the psychobiology of our patients.

, describes a hypothesis that is still at the anecdotal level, based on the subjective experiences of individuals both in sickness and in health. Once again—as with seasonal changes—I have experienced these beneficial effects myself and seen them in my patients, with various poems having specific effects. These observations do not readily lend themselves to the scientific method, so I thought that before such methods are developed, I will share them at the anecdotal level in the hope that they will prove helpful and enjoyable to readers. At this stage, you might consider it more creative-minded than research-oriented.

To answer your question, I enjoy moving fluidly between these different ways of thinking.

PT: What recommendations do you have for doctors who are treating veterans with PTSD?

 There are many established treatments for PTSD. Some involve exposure to the traumatic triggers, either directly (as in Prolonged Exposure), or in the context of a cognitive approach (Cognitive Processing Therapy), or eye movement desensitization and reprocessing. Other approaches do not employ exposure-based techniques, such as interpersonal psychotherapy or TM. I would like to think that someday poetry will also be employed to help patients with PTSD as an ancillary treatment.

PT: June is PTSD awareness month. In your experience, what’s the most important thing for practicing clinicians to know about veterans with PTSD?

 Please be aware how much they suffer. Many of these veterans are not used to talking about their feelings. They feel ashamed about their symptoms, which they often perceive as weakness. They need encouragement and support. It is useful for PTSD patients to associate with other veterans with PTSD, who have undergone therapy for the condition and experienced the rewards. 

PT: Besides the Resilient Warrior Program, are there any other veteran resources you’d recommend?

-National Center for Post Traumatic Stress Disorder. 

-National Alliance on Mental Illness (NAMI) 

This renowned psychiatrist is donating a portion of the proceeds from his book sales to help stop US military veteran suicides. 

Poetry for PTSD and Preventing Suicide

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? 

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?

Suicidal Behaviors and Ideation in Oncology Patients

” by Carey J. Myers, MD, PhD, and Carolina Retamaro, MD

We understand that the authors focused on assessments for psychopathology and suicide risk in patients undergoing disease-directed cancer treatments. In the section “Is Refusal of Treatment a Form of Suicide?” they touch on the concept that (consistent with long-held personal health values and in the absence of contributing psychiatric illness) some patients may choose to refuse—or start and eventually discontinue—disease-modifying therapies with the aim of letting their disease take its natural course, even though that might hasten death. What they do not explore are more active forms of hastening death.

We wish to address this omission. Ten states and the District of Columbia, representing roughly 22% of the United States population, have now legalized Medical Aid in Dying (MAID). While Myers and Retamaro do not directly raise the relationship between cancer suicides and MAID, we believe it important enough to pen a response.

Data from MAID-permitting states shows that patients whose advanced malignancies are likely to lead to their deaths within 6 months comprise the vast majority of those pursuing MAID: 70% to 80% of MAID deaths 

 Broadly, MAID laws allow terminally ill adults with decision making capacity to request and receive from a willing prescriber a lethal prescription to self-administer at the time of their choosing. All current state laws explicitly stipulate that such deaths are not suicide. The District of Columbia statute, for example, asserts that, “actions taken in accordance with this act do not constitute suicide, assisted suicide, mercy killing, or homicide.”

 Maine’s statute adds that state reports may not refer to acts committed under this Act as 

 and Washington State’s statute instructs that “state reports shall refer to practice under this chapter as obtaining and self-administering life-ending medication.”

 Such stipulations guide how to understand the practice, how to complete death certificates, and how to prevent insurers from refusing to pay death benefits. Most importantly, they are intended by lawmakers to help avoid the stigma of suicide.

A large and growing literature outlines the differences between decisions to decline disease-modifying treatments (or directly hasten one’s own death) and the psychopathology associated with suicidal behavior.

 The latter may trigger efforts at suicide prevention and intervention, sometimes even against an individual’s will.

 And while cases with characteristics of both conventional suicides and MAID do occur, clinicians must be prepared to distinguish between them in order to 

This does not challenge the undeniable fact that some cancer patients die by (conventional) suicide. We simply argue that MAID is not the same as those deaths.

We recommend that professionals in jurisdictions with MAID familiarize themselves with relevant statutes, and that terminally ill oncology patients receive accurate information about their rights under the law. Together with accurate predictions about prognosis and expected outcomes of available treatments, this information is essential for physicians who want to work skillfully and humanely with cancer patients, especially those who are expressing doubts about proposed treatment, or articulating a preference for hastened death.

is Maddie Katz Professor of Palliative Care Research and Education at the UCLA David Geffen School of Medicine, where he is Vice Chair for Clinical Affairs in the Department of Psychiatry. He is Board Certified in Psychiatry and Hospice/Palliative Medicine. 

is an emeritus professor of psychiatry at Tufts University School of Medicine and an emeritus professor of psychiatry at the University of Massachusetts-Baystate Medical School. He is the author of 

 and a Guggenheim fellow in Health & Medicine

is a professor of bioethics and psychiatry in the School of Medicine, Case Western Reserve University

is Distinguished Professor of Philosophy and Medical Ethics at the University of Utah. She has authored, co-authored, edited, or co-edited some twenty books, including

The Ethics of Suicide: Historical Sources

 She has been named one of the “Mothers of Bioethics.” 

 has been in the private practice of general and forensic psychiatry for over 35 years. Active in the American Psychiatric Association at both national and local levels, she is past president of Washington Psychiatric Society. 

is professor of psychiatry at the Mayo Clinic.

1. Oregon Health Authority. Oregon death with dignity act. February 26, 2021. Accessed June 10, 2021. 

2. California Department of Public Health. California end of life option act 2019 data report. July 2020. Accessed June 10, 2021. 

3. Washington State Department of Health. 2018 death with dignity act report. July 2019. Accessed June 10, 2021. 

4. District of Columbia Law 21-182(16). Death with Dignity Act of 2016.

5. LD 1313(HP 948). An Act to Enact the Maine Death with Dignity Act.

6. 70.245.180(1). The Washington Death with Dignity Act.

7. Puts MT, Tapscott B, Fitch M, et al. A systematic review of factors influencing older adults' decision to accept or decline cancer treatment. 

8. Strouse TB. Requests for PAD and the assessment of capacity. 

9. Cohen LM, Steinberg MD, Hails KC, et al. Psychiatric evaluation of death-hastening requests. Lessons from dialysis discontinuation. 

10. Yager J, Ganzini L, Nguyen DH, Rapp EK. Working with decisionally capable patients who are determined to end their own lives. 

11. Bostwick JM, Cohen LM. Differentiating suicide from life-ending acts and end-of-life decisions: a model based on chronic kidney disease and dialysis. 

12. Creighton C, Cerel J, Battin M. Statement of the American Association of Suicidology: “Suicide” is not the same as “Physician Aid in Dying.” American Association of Suicidology. October 30, 2017. Accessed March 30, 2021. 

Patients with terminal illnesses may choose to refuse treatment or even hasten their own deaths, but is that the same thing as suicide?

A New Question in End-of-Life Ethics

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

Canada just passed a law that radically changes the boundary between acceptable and unacceptable medical practice and has opened a path to euthanasia for patients with psychiatric illness who find their conditions unbearable.

Unfortunately, this is not a new phenomenon. Several countries allow psychiatric patients who are suicidal to voluntarily receive death by lethal injection (euthanasia) or a self-administered prescription for lethal medication (assisted suicide) from physicians. In Belgium, the Netherlands, and Luxembourg (collectively known as the Benelux nations) these practices first emerged in 2002, after laws were passed permitting medically assisted death for patients whose physical or psychological suffering was unbearable and 

could not be effectively treated by acceptable means

 A terminal condition was not a necessary criterion. This opened the door for some psychiatric patients in those countries to have suicide provided for them rather than prevented. It is documented that between 100 and 200 psychiatric patients are euthanized upon request annually between Belgium and the Netherlands (

In concerned response to these 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.”

permitting medical euthanasia and physician-assisted suicide

, together known as Medical Aid In Dying (MAID).

 By November 2020, more than 13,000 individuals nearing the end of life had been voluntarily euthanized 

To be eligible, a patient’s natural death must be predicted to be reasonably foreseeable. This uniquely Canadian term was not statutorily defined, but it was understood to be associated with the end of life—how close was undetermined. Because death from mental disorders was not considered to be strongly predictable, mental illnesses were not eligible conditions. This feature of the law essentially prevented the kind of psychiatric euthanasia practiced in the Benelux countries.

 challenged the constitutionality of the reasonably foreseeable restriction.

 As a result, a new federal bill was introduced to extend euthanasia eligibility, without the previous restriction. This new initiative, 

, followed the Benelux model; it removed the prior exclusion of those who have with nonterminal chronic illnesses and permitted euthanasia for those whose psychological or physical suffering is deemed intolerable and untreatable.

Initially, Bill C-7 clearly excluded psychiatric disorders, which was at least implicit 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 C-14’s scope discriminated against those with mental illnesses. Ironically, in its efforts to promote parity, the Canadian Psychiatric Association was such a voice. As an organization, it declared: “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, which considered Bill C-7 this February. 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 allowing MAID for mental illness

 available within 18 months of the bill passing.

 When the modified legislation was returned to the House of Commons, the discussion was quickly shut down by a liberal coalition and the bloc party from Quebec (a province that promotes euthanasia and aims to restrict conscientious objection to euthanasia by health care professionals). A vote was forced, and on March 17, 2021, the C-7 expansion of euthanasia in Canada 

, complete with the last-minute amendment to sunset the mental illness exclusion after 2 years.

This 2-year interval is to be used to create an expert panel to establish standards for evaluating patients and procedures to distinguish between patients with psychiatric disorders whose suicide should be prevented from those whose for whom it could be provided. However, as Alex Schadenberg, the executive director of the Euthanasia Prevention Coalition, noted 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, which fought to forestall the inclusion of psychiatric disorders for euthanasia.

The latest law is disappointing but unsurprising considering the huge pushes for parity and nondiscrimination at all costs. Unlike the in United States, health care in Canada is considered a charter (constitutional) right. Thus, once MAID became a medical procedure, excluding patients with psychiatric illness from this right was nearly impossible.

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

 Indeed, Belgium and the Netherlands are now debating the 

extension of euthanasia beyond medical conditions

 to include those who feel they have a completed life

There is even discussion of de-medicalizing euthanasia by 

 Pegasos, a self-proclaimed “voluntary assisted dying association” based in Basel, Switzerland, 

Many psychiatrists in Canada are deeply concerned by the recent developments. In the face of 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.

Similar significant objection comes from the 

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

 also expressed strong worry about how Bill C-7 impacts individuals with chronic disabilities

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.

strong objection among Canada’s First Peoples

, due to conflicts with cultural values, their limited access to state-of-the-art treatments, and staggering suicide rates in that population.

 Similarly, the Canadian Catholic Bishops, who are always opposed to euthanasia, have been left 

Bill C-7 also sets up a 2-tier system, abolishing some of the original 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. Ironically, it is not unusual to have to wait much longer than that in Canada to get psychiatric consultation, treatment, and other resources.

Moreover, there is no requirement that additional, evidenced-based treatments be implemented, although patients are urged to give all treatments serious consideration. Even Belgium, which is known for its liberal approach, recently added guidelines that individuals applying for euthanasia for a mental disorder should not have refused any evidenced-based treatments.

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.

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

 and the World Medical Association “is 

 Nevertheless, these types of laws have been adopted around the world, most recently in New Zealand, Spain, Portugal, and several states in Australia. In US states, as in Canada, attempts have been made to 

 The justifications made in debate for euthanasia and assisted suicide (eg, autonomy, self-determination, and intolerable suffering) are now being applied to psychiatric disorders, despite lack of any agreement that treatment for psychiatric disorders are ever futile or that suffering is truly irremediable.

Bill C-7 and similar laws would represent a remarkable shift in the deep ethos of psychiatry, in which psychiatrists would have to decide which suicides should be prevented and which should be abetted.

Karandeep Sonu Gaind, MD, past president of the Canadian Psychiatric Association and a fierce critic of the MAID expansion to psychiatric patients, noted that less privileged patients have a much harder time accessing medical care in general, especially psychiatric treatment. He lamented the passing of C-7 in a 

So thank you Canada, powers that be,
For ensuring that our smooth passings
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
Of my choice, my voice,
There will be no way of knowing.

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland; a clinical assistant professor of psychiatry at the University of Maryland; and a member of the teaching faculty at Tulane University in New Orleans, Louisiana.

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

. June 21, 2018. Accessed April 28, 2021. 

https://www.psychiatrictimes.com/view/psychiatrist-visits-belgium-epicenter-psychiatric-euthanasia#

2. du Bus C. Euthanasia in Belgium: analysis of the 2020 Commission Report. 

. November 16, 2020. Accessed April 28, 2021. 

https://www.ieb-eib.org/en/news/end-of-life/euthanasia-and-assisted-suicide/euthanasia-in-belgium-analysis-of-the-2020-commission-report-1921.html

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

https://www.euthanasiecommissie.nl/binaries/euthanasiecommissie/documenten/jaarverslagen/2019/april/17/index/RTE_jv2019_ENGELS_gecorrigeerd.pdf

4. Komrad MS. APA position on medical euthanasia. 

. February 25, 2017. Accessed April 28, 2021. 

https://www.psychiatrictimes.com/view/apa-position-medical-euthanasia

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

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

https://www.psychiatrictimes.com/view/medical-euthanasia-canada-current-issues-and-potential-future-expansion

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

http://alexschadenberg.blogspot.com/2020/10/there-have-been-approximately-19000.html

7. Health Canada. First annual report on medical assistance in dying in Canada, 2019. July 2020. Accessed May 10, 2021. 

https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html

8. Rousseau S, Turner S, Chochinov HM, et al. A national survey of Canadian psychiatrists’ attitudes toward medical assistance in death. 

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

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

https://www.thestar.com/news/canada/2019/09/11/quebec-court-invalidates-portions-of-medical-aid-in-dying-laws-as-too-restrictive.html

10. First session, forty-third Parliament, House of Commons of Canada. Bill C-7: an act to amend the Criminal Code (medical assistance in dying). first reading February 24, 2020. Parliament of Canada. Accessed April 28, 2021. 

https://parl.ca/DocumentViewer/en/43-1/bill/C-7/first-reading

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

https://www.cpa-apc.org/wp-content/uploads/2020-CPA-Position-Statement-MAID-EN-web-Final.pdf

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

. February 9, 2021. Accessed April 28, 2021. 

https://www.ctvnews.ca/politics/senators-amend-maid-bill-to-put-18-month-time-limit-on-mental-illness-exclusion-1.5302151

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

. March 17, 2021. Updated March 19, 2021. Accessed April 28, 2021. 

https://globalnews.ca/news/7703262/canada-senate-passes-bill-c-7/

14. Smith W. Euthanasia spreads in Europe: several 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/

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

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

https://www.dutchnews.nl/news/2020/07/euthanasia-law-proposed-for-healthy-over-75s-who-feel-their-lives-are-complete/

16. Cohen-Almagor R. Euthanizing people who are “tired of life.” In: Jones DA, Gastmans C, MacKellar C, eds. 

Euthanasia and Assisted Suicide: Lessons from Belgium

. Cambridge University Press; 2017:188-201.

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

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

https://www.irishtimes.com/news/world/europe/euthanasia-debate-in-netherlands-takes-an-unwelcome-twist-1.4013718

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

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

https://www.bioedge.org/mobile/view/a-new-swiss-group-caters-for-dutch-who-are-not-eligible-for-euthanasia/13673

19. Maher J. Why legalizing medically assisted dying for people with mental illness is misguided. Canadian Broadcasting Corporation. February 11, 2020. Accessed April 28, 2021. 

https://www.cbc.ca/news/opinion/opinion-assisted-dying-maid-legislation-mental-health-1.5452676

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

. March 24, 2021. Updated March 27, 2021. Accessed April 28, 2021. 

https://www.thechronicleherald.ca/opinion/local-perspectives/patricia-neves-disability-is-not-a-fate-worse-than-death-567935/

21. 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. United Nations Human Rights: Office of the High Commissioner. February 3, 2021. Accessed April 28, 2021. 

https://spcommreports.ohchr.org/TMResultsBase/DownLoadPublicCommunicationFile?gId=26002

22. Ruck A. First Nations leaders say Bill C7 goes against their beliefs and values. 

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

Suicide

Is it Time to Leave the Doctor’s Office?

Poetry for PTSD and Preventing Suicide

Are Psychiatrists who Assist in Suicide Betraying Their Professional Values?

A New Question in End-of-Life Ethics

First, Do No Harm: New Canadian Law Allows for Assisted Suicide for Patients with Psychiatric Disorders

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

6 Lessons From a Tragedy

COVID-19 Loneliness

Suicidal Ideation and Behaviors in Oncology Patients

Risky Business: The Higher Risk of Nonsuicidal Self Injury in Bisexual Individuals