Suicide among veterans with amyotrophic lateral sclerosis

Abstract

Background: The purpose of this study was to estimate the risk of death by suicide for those with amyotrophic lateral sclerosis (ALS) seeking care within the Veterans Health Administration (VHA).Methods: This was a retrospective, cohort study. Extended Cox regression models were used to compare the hazard of suicide between the ALS and the unexposed groups.

Hastened death in veterans with amyotrophic lateral sclerosis

“…In this issue of the Journal, Lund and colleagues provide further insight into this conundrum. They identify a fourfold increase in suicide (self‐inflicted, not physician‐assisted) in a notably large cohort of ALS patients receiving care from the Veteran's Health Administration 4 …”

“…What questions requisite to resolution of this complex problem remain unanswered? Is hastened‐death interest, either with or without physician assistance, related to depression? 2,5‐15 Does interest in hastened death by either method represent an expedient attempt to exercise control over future limitations imposed by disease progression, particularly in jurisdictions or medical health systems like the Veteran's Health Administration where lawful hastened‐death options do not exist? 3,4,6‐8,12,16 If depression is the underlying cause for hastened‐death interest in ALS patients, can it be reliably detected in a disorder in which disease manifestations (e.g., pseudobulbar affect) overlap significantly with affective symptomatology and where treatments are used for both affective and somatic symptoms? 5,9 If depression is a reaction to the psychosocial consequences of the ALS diagnosis, is it potentially symbiotic with potential adverse psychosocial influence of prior military experience as implied by the increased risk of suicide in this latter population? 17 Is depression a biological byproduct of FTD, with or without heritable influence, potentially more prevalent in an ALS cohort, that could precede the more readily recognizable somatic manifestations of the disease? 5,8,10,11 …”

“…The authors highlight an increased rate for self‐inflicted suicide among US military veterans with ALS. It is reported that this is frequently accomplished with the use of firearms, a capability potentially facilitated by previous military training 4 . At the same time, the authors inform us that physician‐assisted suicide is precluded as an option for those receiving care from the Veterans Health Administration as a result of the Assisted Suicide Restriction Funding Act of 1997 4 .…”

“…It is reported that this is frequently accomplished with the use of firearms, a capability potentially facilitated by previous military training 4 . At the same time, the authors inform us that physician‐assisted suicide is precluded as an option for those receiving care from the Veterans Health Administration as a result of the Assisted Suicide Restriction Funding Act of 1997 4 . This is true even though physician‐assisted suicide may be viewed by terminally ill patients as a means of retaining control, thus reducing interest in self‐inflicted suicide as a less‐regulated, often premature, and frequently less humane means of hastened death 8,18,19 .…”

“…They identify a fourfold increase in suicide (self-inflicted, not physician-assisted) in a notably large cohort of ALS patients receiving care from the Veteran's Health Administration. 4…”