Interpretation: A 2A R activity in forebrain neurons is critical to the control of motor activity, whereas brain cells other than forebrain neurons (likely glial cells) are important components for protection against acute MPTP toxicity.

Patients with comorbid schizophrenia and panic symptoms share a distinct clinical presentation and biological characteristics, prompting some to propose panic psychosis as a separate subtype of schizophrenia. Less is known about these patients’ neuropsychological profiles, knowledge of which may facilitate target-specific treatments and research into the etiopathophysiology for such cases. A total of 255 schizophrenia patients with panic disorder (n=39), non-panic anxiety disorder (n=51), or no anxiety disorder (n=165) were assessed with the Wechsler Adult Intelligence Scale – Revised, the Wisconsin Card Sorting Test, the Trail Making Test, the Controlled Oral Word Association Test, the Animal Naming subtest of the Boston Diagnostic Aphasia Examination, and the Wechsler Memory Scale – Revised. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale. Patients with panic disorder demonstrated a higher verbal IQ and better problem solving, set switching, delayed recall, attention, and verbal fluency as compared to schizophrenia patients without comorbid anxiety. The schizophrenia-panic group reported a higher level of dysthymia on stable medication. Our findings suggest that patients with schizophrenia and comorbid panic disorder exhibit distinct cognitive functioning when compared to other schizophrenia patients. These data offer further support for a definable panic-psychosis subtype and suggest new etiological pathways for future research.

Psychiatrists face complex, vexing, and often conflicting issues in assessing and managing patients with advanced medical illnesses who are determined to end their own lives. Substantial differences of opinion exist among psychiatrists regarding the roles they might take with such patients when the patients are decisionally capable and do not have clear-cut psychiatric disorders. Even those with psychiatric diagnoses often possess rational deliberative abilities and may make decisions to hasten death that are not impacted by their psychiatric disorder. How psychiatrists interact with these patients may be influenced by contradictory and even incompatible ethical, psychological, social, cultural, and professional biases. Tensions often exist between patients' autonomous preferences regarding their wish to die and psychiatrists' usual approaches to suicide prevention. To consider these issues, we review some ethical, legal, psychological, social, and clinical concerns; potential interventions; and support for psychiatrists caring for decisionally capable patients with advanced medical illness who wish to end their own lives. Although psychiatrists' work strongly focuses on suicide prevention, harms might result if suicide prevention becomes the only focus of treatment plans for these patients. We recast benefits and harms in such situations and make suggestions for assessing and managing such patients and for potentially offering assistance to families and other survivors. While psychiatrists should carefully think through each case on its own merits and seek consultation with experts, they should not act reflexively to prevent all deaths at any cost. We argue they may, in some cases, honor patients' and families' wishes and even collaborate with them around decisions to hasten death.

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To the Editor: Unlike Yager and colleagues, 1 we do not believe that psychiatrists face end-of-life issues with "knee jerk reactions that consider all intentions to end one's life as irrational and to be stopped at all costs. " Rather, psychiatrists approach the desire to end one's life from the perspective of venerable, well-reasoned principles of Hippocratic medicine, wrought over two millennia. Similarly, when patients request "assistance" in ending their lives, psychiatrists bring a specialized skill set to bear on the request, independent of any particular DSM diagnosis and without presumption of "mental illness." Our aim is to help patients mitigate suffering, find some path to a better future, and, ideally, find meaning, even in the face of terminal illness. This approach is no mere reflex; rather, it represents the fundamental ethos of psychiatry, deployed with deep reflection and devotion.A central question raised by Yager et al 1 is whether it is ethical for psychiatrists to be involved in competency assessments in the context of so-called "physician assisted death. " (We endorse, and herein employ, the terminology advocated by the American College of Physicians and the American Medical Association's Council on Ethical and Judicial Affairs; ie, "physician-assisted suicide" [PAS]). 2,3 If, as we believe, PAS is inherently unethical-a position also taken by the World Medical Association 4 -then it is perforce unethical for psychiatrists to be involved in performing competency assessments on patients requesting PAS. By analogy: the American Psychiatric Association has taken the position that psychiatrists should not perform competency assessments on prisoners slated for execution, though psychiatrists are permitted to relieve the prisoner's "acute suffering" while he is awaiting execution. 5 Again, by analogy, we believe that, where PAS or euthanasia is legal in the United States and internationally, the psychiatrist's role vis-à-vis patients requesting PAS should be limited to (1) determining if the patient is at immediate risk of self-harm, in which case emergency procedures could be initiated, and (2) alleviating acute suffering, such as panic attacks or extreme emotional distress, using appropriate psychiatric interventions. We also envision the possibility that a connection with a psychiatrist may help the patient work through existential and psychosocial issues that may underlie the wish for death or assisted suicide.