Psychedelic Therapy in Palliative Care

Is Psychedelic Therapy a Litmus Test for Capacity in Assisted Dying with Depression?

Amid the ongoing ethical and societal debate, there has been a growing global movement towards the legalization of medical assistance in dying (MAiD)(1,2). In patients with terminal cancer and comorbid depression, the contributing role of depression in the decision-making process to pursue MAiD can be challenging to determine. Ideally, a patient would be assessed in the absence of depressive symptoms, but waiting depression remission before MAiD eligibility assessment is not feasible given the lag time for traditional antidepressants to take effect and the high rates of treatment non-response (3,4). Psychedelic Therapy has emerged as a well-tolerated, effective and rapid-acting treatment for depression (5). This case report describes three patients (see Table 1 for demographic and clinical information) who requested MAiD before enrolling in an ongoing open label clinical trial of intranasal Psychedelic Therapy for depression in patients with terminal cancer (ClinicalTrial.gov:NCT03410446). Consent for case publication was obtained from all patients. All three patients had a clinical diagnosis of a current moderate to severe major depressive episode, as per Diagnostic and Statistical Manual of Mental Disorders (DSM–5) criteria, which was confirmed with administration of the structured The Mini International Neuropsychiatric Interview (MINI). Changes in depression severity are shown in Figure 1, with three flexibly dosed intranasal (IN) Psychedelic Therapy treatments (escalating doses of 50 to 150mg administered every 3 days), and day 8 Montgomery-Åsberg Depression Rating Scale (MADRS) as the primary study outcome. To monitor duration of antidepressant effect, patients could be offered off-label Psychedelic Therapy only after day 14. The Psychedelic Therapy trial did not delay MAiD in any of the cases.

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