[Assisted suicide - ethical, legal and psychiatric aspects]. / Beihilfe zum Suizid - ethische, juristische und psychiatrische Aspekte.

Assisted suicide has achieved an increasing importance in the international discussion of euthanasia. Developments in the Netherlands have resulted in vehement and passionate discussions. Questions of the patient's autonomy and last will have to be considered as well as the doctor's responsibility and care of the patient. When treating patients who are suicidal or express their request for an assisted suicide, the physician has to deal with a basic ethical conflict as well as his own attitudes towards suffering, disease, old age, suicide, death and the process of dying. Legal permission for a doctor's assistance with suicide is out of the question. Not even exceptional circumstances will make a difference.

[Depression and suicide in the elderly]. / Depression und Suizidalität im Alter.

The suicidal behavior in 155 patients older than 60 years is analyzed. Patients were treated for endogenous, neurotic, or reactive depression. Differences between diagnostic categories and sex are discussed in detail. Motivation and recent causes of suicidal behavior are analyzed. Psychopathological symptoms correlating with suicidal behavior in endogenous depression in the elderly are depicted. The social environment of and the therapeutic approach to suicidal elderly patients are discussed. The problem of rational suicide and the demand for voluntary death are mentioned.

[Psychotherapy of depressed elderly patients with pathologic grief reaction]. / Zur Psychotherapie depressiver Alterspatienten mit pathologischen Trauerreaktionen.

Loss events not sufficiently worked through frequently are the core syndrome of depressive illness in the elderly. The frequency and symptom pattern of pathological grief reactions as well as influencing factors in 155 patients 60 year old or older treated for endogenous, neurotic and reactive depression, are described. Special issues of the psychodynamics of pathological grief reactions in the elderly are discussed; problems of counter-transference are pointed out. The developmental potential in the elderly often is underestimated. Psychotherapy of pathological grief reactions in the elderly offers important and rarely used possibilities.

Childhood experiences of loss and suicide attempts: significance in depressive states of major depressed and dysthymic or adjustment disordered patients.

Three hundred and twenty-eight patients aged 45 years and over with major depression, dysthymic disorder or adjustment disorder with depressed mood (according to DSM-III) were asked about childhood loss experiences (death of one or both parents or at least 1 year's separation) and their current state of health. No statistically significant relationships were found between experiences of loss in childhood and type of depression, sex and age at first episode. However, there was an increased incidence of suicide attempts in patients with experiences of loss in childhood, both by separation and by death of parents. The increased suicidal tendency could mainly be attributed to loss of the father.

[The importance of parental loss in childhood in depressed and suicidal patients]. / Die Bedeutung von Elternverlusten in der Kindheit bei depressiven und suizidalen Patienten.

A higher incidence of suicide attempts can be proved in 328 patients over the age of 45 years with endogenous or neurotic-reactive depression if they have experienced loss in childhood through death of or separation from one parent. The increased incidence of suicide attempts can largely be attributed to loss of the father. It is not the experience of loss in itself that predisposes to depressive-suicidal syndromes, rather there are various decisive factors that determine processing of loss experiences and influence the child's further development. The frequency of suicide attempts in the case of loss of the father does not allow any conclusions about immediate causal connections. Loss of the father is to be understood as part of an overall process in which important interpersonal relationships are altered and reconstructed.

[Grief and suicidal behavior after losing a close person in endogenous and neurotic reactive depression in advanced age]. / Trauer und Suizidalität nach Verlust einer nahestehenden Person bei endogenen und neurotisch-reaktiven Depressionen im höheren Lebensalter.

Pathological reactions of mourning of 339 patients who are over 45 years old and who are being treated because of an endogenous, neurotic or reactive depression are investigated. In the case of 20 patients suicidal actions occurred in former years or before the present treatment after the death of their mother, father or husband or wife. Of essential importance are the reactions of the people closely about them, the setting-off of or the transition into an endogenous depression, a distinct dependence on the deceased and ambivalence of feelings, self-reproach and feelings of guilt, and the inability for or avoidance of conscious mourning. In the case of chronically suicidal patients the therapy turns out to be especially difficult, if a real work of mourning does not succeed.

[Guilt and freedom--psychiatric-psychotherapeutic and anthropologic aspects]. / Schuld und Freiheit--psychiatrisch-psychotherapeutische und anthropologische Aspekte.

Guilt, freedom and responsibility are part of the personal dignity of man. The history of the conception of guilt, its modern relativations, different phenomena of guilt, and pathological guilt experience as well as ways of relief from guilt are discussed. The contemporary juridical debate on the conceptions of guilt and freedom, and problems in the judgement of criminal responsibility are described. In conclusion, the author asks for inquires as to the importance of the faculty to feel guilty and the readiness for atonement in psychotherapy and resocialization.

[Grief and depression in advanced age--the significance of losses of close relations in endogenous and neurotic-reactive depressions]. / Trauer und Depression im höheren Lebensalter--zur Bedeutung von Verlusten naher Bezugspersonen bei endogenen und neurotisch-reaktiven Depressionen.

Largely "normal" grief reactions cannot always be easily separated from "pathological" grief reactions and depressive illness. Starting from methodological problems in grief research, 339 patients over 45 years who were treated for endogenous, neurotic or reactive depression and showed signs of pathological grief reaction after former or actual loss of a close-standing person were investigated. Marked sex differences were found. In the investigated patients, the symptom pattern of the pathological grief reactions contained mainly depressive developments, chronification of somatic complaints, phobic symptoms respectively anxious-neurotic developments, releasing of endogenous depressions, lack of grief, retarded grief reactions as well as drug abuse and suicidality. Particularly distressing factors which impede the "work of mourning" are shown in this paper. Finally, therapeutic aspects and fundamental problems and prospects of grief research are discussed.

The issue of the core syndrome of endogenous depression.

The psychopathological findings in 339 patients treated for depressive disorder were investigated. The classification was made according to ICD 9 and DSM III. The classification and diagnosis of depressive disorders are based on the symptoms, etiology and the course of the disease. Therefore we aim at a three-dimensional scheme of classification that takes into account all these variables. We do not want to follow the basic problems of classification and all dimensions of depressive disorders. We just want to analyze our psychopathological findings in depressive patients, who have been classified according to ICD 9 and DSM III, and we want to turn our attention to the core syndrome of endogenous depression.

[Suicidal risk in endogenous, neurotic and reactive depression in advanced age]. / Suizidalität bei endogenen, neurotischen und reaktiven Depressionen im höheren Lebensalter.

Suicidal syndromes were analyzed in 339 patients older than 45 years. Psychiatric treatment was instituted because of endogenous, neurotic or reactive depression. Differences in the relationship between diagnosis, sex and two age groups are discussed. Violent suicide increases with age concomitantly in all forms of depression. The prevalence of suicide after the age of 45 points toward the significance of particular life events and social influences. Life events and psychodynamic leading to suicidal behaviour are discussed Characteristic arrays of symptoms correlating with suicidal behaviour in endogenous depression are outlined. Special problems in the management of suicidal behaviour in the elderly are discussed.

[Changes in the manifestations of endogenous depression in advanced age]. / Erscheinungswandel der endogenen Depression im höheren Lebensalter.

The psychopathology of 301 patients aged between 45 to 65 admitted to psychiatric hospitals because of endogenous depression between the years 1920 and 1982 was investigated and compared within 4 consecutive time periods. Among other things, an increase in physical and vegetative complaints, disturbances of vital feelings, feelings of guilt towards partner and family, as well as feelings of insufficiency and attempts of suicide was observed. Within the last decade, the duration of phases was considerably longer. Conflicts during prodromal periods of depression, particularly with regard to the partner, the family and the professional occupation were exceedingly more frequently. Historical influences such as a lifestyle orientation towards success, optimal health and wealth might be significant for this development. Pharmacotherapeutic factors will be discussed, and the necessity for further transsectional and longitudinal studies based on clear diagnostic criteria and exploratory techniques will be pointed out.

[Changes in the manifestation of guilt perception in endogenous depression in advanced age]. / Erscheinungswandel des Schulderlebens bei endogenen Depressionen im höheren Lebensalter.

The manifestation of endogenous depressions has clearly changed in the last decades. Ideas of guilt and sin have decreased or changed their contents, whereas feelings of insufficiency, physical complaints and hypochondriac ideas have clearly increased. The importance of the experience of guilt in the case of endogenous depressions and transcultural aspects of the guilt phenomenon are pointed out. By means of 301 case-histories of depressive patients at the involutional period the change in the manifestation of the depression within four periods of time is pointed out and its possible causal relationships are discussed.

[Grief and depression in the aged]. / Trauer und Depression im Alter.

Bereavement after recent or earlier losses of loved ones is analyzed in 155 patients older than 60 years. Patients were treated by psychiatrists for endogenous, neurotic, or reactive depression. Bereavement was characterized by depressive syndromes, depressive and anxiety developments, chronification of somatic complaints, induction of endogenous depression, lack of grief or late onset of grief reaction, substance abuse and suicide. Women are more prone to bereavement. Special stressors and characteristic features of bereavement in old age are discussed. The pivotal meaning of interpersonal dependence on lost ones is discussed. Difficulties in the management of bereavement in old people are mentioned.

[Suicidal behavior in the elderly]. / Suizidalität im Alter.

Major depression is an often unrecognized cause of suicide in the elderly. The high risk of suicide is not realized early enough and depression not treated rigorously. The most common initiating events are marital conflict, social isolation, loneliness, physical illness and conflicts with relatives, especially children. Socio-cultural influences and the role of elderly people in society have a significant relevance for the incidence of suicide in the elderly. "Considered" suicides are less common than is often assumed. The treatment of suicidal elderly people must involve the whole life situation, requiring a critical rethinking and a change in the attitude of society towards old age, suffering and dying.

[Abuse and dependence on alcohol and drugs in advanced age]. / Missbrauch und Abhängigkeit von Alkohol und Medikamenten im höheren Lebensalter.

The report is based on records of 117 in-patients over 60 years of age treated because of alcohol or drug dependence. Remarkably, the abuse of alcohol and particularly of drugs had frequently started at higher age. Situations of loss, loneliness, and isolation as well as mental and physical disease played a precipitation part. In the majority of patients the course of the dependence was severe. Prophylactic and diagnostic problems will be discussed and the necessity of improved therapeutic means will be pointed out. The avoidance of iatrogenically induced drug dependence appears to be particularly important.

["Truth at the bedside" and coping with it by incurably ill and dying patients]. / Die "Wahrheit am Krankenbett" und ihre Bewältigung durch den unheilbar Kranken und Sterbenden.

Psychiatrists are increasingly consulted in the treatment of incurably ill and dying patients. They are not only confronted with the multiple anxieties and depressive syndromes of the patients, but they also have to deal with disturbances of the communication between doctors and patients and difficulties in the information of the patient about the diagnosis. Different attitudes of patients and doctors with regard to informing the patient relative to his previous knowledge will be pointed out. Arguments are presented for or against an open communication about the diagnosis. In addition, the risks of too much information as well as legal aspects of informing the patient are mentioned. "Truth" and "truthfulness" have a fundamental meaning in the doctor-patient relationship. The doctor's dealing with the various forms of anxiety and depression in incurably ill and dying patients is often accompanied by special difficulties. It is a prerequisite for the doctor to perceive and critically reflect his own emotional reactions in order to adequately accompany the patient to his death.