A BMJ blogger, William Lee, writes of his disquiet following a visit to a meeting held by Dr Philip Nitschke, director of EXIT International, who is in the UK promoting his new ‘guide to suicide’. He describes a strange-sounding meeting with little consideration of the relationship between suicidality and mental illness, and the issue of mental capacity warranting only a cursory mention, including the bizarre recommendation to ‘get a friend to do an MMSE test before your suicide to demonstrate possession of capacity’. Assisted suicide and the ‘right to die’ feature prominently in the news media at the moment. A 45-year-old woman, Debbie Purdey, is seeking clarification of the UK law relating to assisted suicide. She doesn’t want her husband to be prosecuted should he support her in visiting Dignitas, the Swiss organisation providing facilities for euthanasia. Police are currently investigating the case of David James, a 23-year-old left with quadriplegia after sustaining a spinal injury while playing rugby. After several previous attempts he committed suicide at a clinic in Switzerland

Another case has been less widely reported, although I consider it to be no less significant (read about it here). It’s a common scenario that will be familiar to anyone with experience of working in an emergency department – someone presenting with self-poisoning and then refusing treatment. The inquest began last week into the death of Kerrie Wooltorton, a woman with a history of borderline personality disorder, who was taken to Norfolk and Norwich University Hospital after drinking antifreeze (ethylene glycol). On arrival she stated that she did not want treatment and was ‘100 per cent aware of the consequences’. She also brought in a living will (advance directive) that she had written three days previously. The physician responsible for her care thought that she had capacity to make decisions about her treatment and reported that she was ‘calm’ and ‘not agitated’. He felt that it was his ‘duty to follow her wishes’. After consultation with the hospital’s medical director and legal adviser she was not given treatment and died the following day.

The law in the UK (recently codified in the Mental Capacity Act) is clear on the question of treatment for physical illness without consent. If the subject has capacity such treatment would constitute an assault or battery. Yet there are aspects of this case which are troubling. Ms Wootorton had attempted suicide by swallowing antifreeze on nine occasions in less than a year and had previously accepted treatment (including dialysis). She also had a number of recent psychiatric admissions and had been detained under the Mental Health Act. A psychiatrist who saw her in the months before her death said he believed she had the mental capacity to make the advance directive but how can he be certain that this was the case when she wrote it? Given the context of her recent history would there not have been reasonable grounds to doubt her capacity? It’s not uncommon for people turning up in A&E after deliberate self-harm to express ambivalence about treatment and subsequently change their mind, especially in those with borderline personality disorder where impulsivity is a prominent feature. Also, suicidality fluctuates in this group, and if her intent was so clear why come to hospital at all?

These decisions are always difficult and not really made any easier by the Mental Capacity Act. My inclination would have been to treat her on this occasion with an agreement that if she maintained her wish to decline future treatment and in the cold light of day clearly had capacity, an advance directive could be drawn up with the acknowledgment that it was valid by people involved in her care. A paternalistic abuse of a person’s autonomy? Maybe, but what do you think?

The benefits of St John’s wort (SJW) have been widely reported this week following the publication of this study. It’s not, as some articles suggest, a new trial but actually an update of a Cochrane systematic review and meta-analysis. The review is comprehensive, with the addition of some big recent RCTs, and the authors have restricted the inclusion criteria to major depression. The results reinforce those of earlier reviews: SJW is as effective as standard antidepressants in mild and moderate depression with the benefit of fewer side effects.

Perhaps the most interesting finding is that studies from German-speaking countries show much more favourable results. In fact taking out the German studies from the meta-analysis removes any benefit of SJW over placebo. It’s not easy to explain this difference – you can insert your own cultural jokes here. What is notable is that the German trials predominantly recruited from private practices in primary care with a long tradition of prescribing SJW. This contrasts with the remainder where studies were carried out in academic or hospital settings where SJW is not licensed as a drug. Despite matching inclusion criteria there may have been differences between the types of patient entering the trials (selection bias). Andere Länder, andere Sitten.

So given this ‘natural’ alternative why don’t I recommend SJW to people I see with depression? Well in the UK it’s not licensed as a medicine but sold as a dietary supplement, and comes over the counter in a variety of formulations: pills, potions, lotions – you might even to able to smoke it. That means it can be difficult to know what you are getting and dosages in this review varied from 240 to 1800 mg per day. The active ingredient and mechanism of action is still unknown – not that we really understand how standard antidepressants work either. The other concern is the potential for drug interactions. SJW stimulates those liver enzymes that break down medicines such as warfarin, HIV drugs and oral contraceptives rendering them ineffective. Combining it with other antidepressants can also have nasty effects: I had a near miss with a woman starting on the antidepressant sertraline, who hadn’t admitted to SJW use as it was a ‘herb’ she was taking for migraine. So it may be a plant extract but it is certainly not innocuous.

No, it didn’t crop up in the first presidential debate – arguably there were more pressing issues to deal with. But the National Alliance on Mental Illness, a US advocacy group, has posted the replies to a questionnaire on mental health care sent to both Barack Obama and John McCain. Unsurprisingly, health care reform features prominently in the campaign platforms of both candidates. The problems are well known: the US has the most expensive health care system in the world, but 47 million Americans remain uninsured with both life expectancy and infant mortality falling well short compared to other developed nations. Dissatisfaction with the status quo is widespread but there is little agreement about how to change it. Mental health care always struggles to get attention until, of course, cases of gross neglect such as that of Esmin Green come to light. So that NAMI were able to get detailed responses from the two presidential candidates is noteworthy, whatever you think of the responses themselves.

Unlike McCain, Obama did answer all 24 questions that were submitted. In fact he responded by “strongly supporting” every point raised by NAMI: he’s all for guaranteeing comprehensive coverage, improving access to services, increasing funding for all, and awarding all of those living with mental illness a $1 million dollar tax-free lump sum (that last part is fiction, but you get the idea). In other words, an adroit political response: overwhelmingly supportive, but promising nothing too specific.

Although John McCain responded with his own statement (his campaign doesn’t do questionnaires), his comments are certainly more revealing than those made by Obama. Firstly, a positive: he recognises the importance of co-existing psychological disorder in chronic medical illness, stating that untreated depression raises dramatically the costs of treating the physical ailments such as diabetes. Let’s integrate psychological care into general medical practice: not much to argue with there. I’m not so sure about his emphasis on “the central role of personal responsibility” which sounds like a rerun of the ‘mental illness equals lack of moral fibre’ argument.  What comes across most clearly, however, is his enthusiasm for cutting costs, mentioned four times here. At least that’s consistent with his overall approach to health care reform: “Opening up the health insurance market to more vigorous nationwide competition, as we have done over the last decade in banking, would provide more choices of innovative products less burdened by the worst excesses of state-based regulation.” Oh dear.

You might think so looking at newspaper reports of a study examining the effect of paroxetine on sperm quality. It’s well known that antidepressants, the SSRIs in particular, can have sexual side effects: notably a drop in libido and delayed orgasm. In fact the SSRIs have been used pretty effectively as a treatment for premature ejaculation. Sexual dysfunction is one thing but infertility is another, so what does this study by a team of New York urologists actually tell us?

Bear in mind that this is a very small before and after study with no control group, which might explain why it hasn’t appeared in a peer-reviewed publication but did make the BBC News. Thirty-five healthy (and presumably not depressed) men were given paroxetine at doses of up to 30mg daily for 5 weeks. The researchers looked at the men’s semen at baseline and then four weeks into the study. Sperm numbers, motility and morphology were unaffected but the level of damaged sperm DNA rose from a mean of 14% to 30%. Clinically significant? A good question and one that’s debatable according to Allan Pacey, Senior Lecturer in Andrology at the University of Sheffield. More and better research needed seems to be the message. Should this study change practice? I don’t think so. A long list of drugs, both prescribed and recreational, are known to affect sperm quality. What’s reassuring is that most men seem to produce enough of the stuff for their fertility to remain unaffected and sperm quality usually returns to normal once the drug is withdrawn.