Laws permitting assisted suicide may justify the right of even psychiatric patients to end their lives in theory, but the reality of implementing such programs is messy, a study of the Netherlands finds.

Complex medical histories and disagreements among doctors were common elements among the Dutch cases of psychiatric patients who chose legalized assisted suicide or euthanasia, say the researchers who analyzed them.

"When you actually try to implement it even in a setting where there is excellent healthcare, there are a lot of red flags that need to be investigated further," said lead study author Dr. Scott Kim, a psychiatrist and bioethicist at the National Institutes of Health in Bethesda, Maryland.

In some form, assisted death is legalized in Belgium, The Netherlands, Switzerland, Luxembourg, Canada and a few U.S. states, Kim and his colleagues write in JAMA Psychiatry.

"In Belgium and The Netherlands they have a much more expansive law that doesn't regard diagnosis as important," Kim told Reuters Health. The ambiguity allows the law to also apply to patients with psychiatric illnesses.

People with treatment-resistant depression tend to be the focus of debate over assisted suicide for psychiatric illnesses, the researchers note. But little is known about who actually uses the 2002 law that formalized euthanasia practices in the Netherlands.

For the new study, the researchers examined case summaries from Dutch regional euthanasia review committees posted online by June 2015. The committees are charged with ensuring that "due care" was given by the doctors involved in each case.

There were 66 summaries of psychiatric assisted suicide cases that took place between 2011 and 2014, representing the majority of assisted suicides involving psychiatric patients known to have occurred during that period.

Overall, about a third of the people helped to end their lives were age 70 years or older, 44 percent were between ages 50 and 70 and about a quarter were 30 to 50 years old. Seventy percent were women.

While fully 55 percent of patients were diagnosed with depression, the others had a number of different conditions, including psychosis, posttraumatic stress disorder or anxiety, neurocognitive issues, pain without any physical cause, eating disorders, prolonged grief and autism.

About a quarter of patients' suicides were assisted by psychiatrists, and about one in five patients were treated by unfamiliar doctors - the majority from a mobile assisted suicide clinic funded by a Dutch right to die organization.

The researchers also found that about one in 10 patients receive no outside input from psychiatrists, and about a quarter of cases involved disagreement between the doctors treating the patient.

Dr. Paul Applebaum writes in an accompanying editorial that the findings "raise serious concerns about the implementation of physician-assisted dying for psychiatric patients."

For example, over half of the cases also had personality disorders, which raises questions about "the stability of the expressed desires to die," writes Applebaum, of the New York State Psychiatric Institute and Columbia University's Department of Psychiatry in New York City.

When one considers the subjective criteria used to determine a person's eligibility for assisted suicide or euthanasia in The Netherlands, Dr. Aaron Kheriaty said, it's no surprise to see such a wide range of ages and psychiatric diagnoses among the patients who choose to end their lives this way.

"To me that's very concerning," said Kheriaty, a psychiatrist and director of the Medical Ethics Program at the University of California, Irvine.

Some of the conditions listed in the cases are potentially treatable, he said.

"I think when we open the door to assisted suicide for psychiatric patients, we risk abandoning patients when there may be hope," said Kheriaty, who was not involved with the new study.

Kim said there is currently no standardized system for reporting these cases, and the availability of data varies by country.

"I think there needs to be a lot more transparency of what actually happens when assisted suicide or euthanasia is provided," he said. "Right now the Dutch system is the most transparent."

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