Palliative Psychiatry May Ease Suffering, Protect Against Futile Treatments

Some people with serious and enduring mental illness—who have exhausted evidence-based treatment and are declining further care—may benefit from a palliative psychiatry approach.

Although the United States has been slower to adopt palliative medicine than many other countries, this outgrowth of the hospice movement became its own medical specialty in this country in 2006. Its scope has widened considerably in the last two decades and is increasingly being provided earlier in the disease course and even alongside curative treatment. A palliative approach is being used to care for people with a variety of serious chronic illnesses, including psychiatric disorders.

“While curative psychiatry primarily aims at remission of mental illness, by contrast palliative psychiatry works around the mental illness focusing on symptom relief, improvements in day-to-day functioning, increases in quality of life, and harm reduction with the fewest restrictions,” Manuel Trachsel, M.D., Ph.D., head of the Clinical Ethics Unit at the University Hospital of Basel and senior lecturer at the Medical Faculty of the University of Basel in Switzerland, told Psychiatric News.

“Palliative psychiatry places great emphasis on maintaining the respect of people with severe and persistent mental illness who may face stigma and discrimination and have often been forced to undergo burdensome or futile treatments for most of their lives,” Trachsel said. “Palliative psychiatry aims to give people the opportunity to maintain a sense of control and autonomy in their lives.” To that end, it can help protect against polypharmacy, overly aggressive treatment, or even neglect.

Even with optimal treatment, about one-fifth of people with serious mental illness (SMI) do not achieve remission or an acceptable quality of life. In addition, with each unsuccessful treatment, the evidence base for further treatment becomes thinner, and the probability of symptom reduction declines, according to Anna L. Westermair, M.D., and colleagues in the December 2022 issue of the Australian & New Zealand Journal of Psychiatry. At the same time, intolerable side effects become more likely.

“The idea of palliation is that we focus less on what is called in oncology ‘the war against the disease,’ which sometimes takes the person out of the equation, and more on reduction of suffering … and what the patient wants,” Thomas B. Strouse, M.D., a psychiatrist and palliative care specialist at the Stewart and Lynda Resnick Neuropsychiatric Hospital at the University of California at Los Angeles, told Psychiatric News. “Psychiatry has been slower than the rest of medicine to recognize that a palliative focus of improving quality of life, rather than solely extending quantity of life, is an important and valid treatment goal.”

Although psychiatric illnesses tend to be thought of as having no organic basis, many people with these disorders develop life-endangering comorbidities as they age, Strouse said. In fact, people with SMI have a much higher prevalence of chronic diseases that tend to be diagnosed later in life and are more severe than those of the general population. According to a viewpoint by Kwok Ying Chan and colleagues in JAMA Psychiatry in September 2023, patients with SMI are only one-third as likely to receive palliative care as the general population (only 0.5% versus 1.7%).

People who have received repeated rounds of involuntary, unsuccessful treatments; who are miserable and suffering; who refuse curative treatments; and/or who are near end-of-life due to medical comorbidities may be candidates for a palliative approach, Joel Yager, M.D., professor emeritus of psychiatry at the University of Colorado School of Medicine at the Anschutz Medical Campus, told Psychiatric News. They may include people with severe and enduring forms of anorexia, major depression, schizophrenia, or personality disorders.

“Palliative psychiatry does not impose treatments on patients; rather, it allows them to pick and choose from a menu of treatment options. At its core, it is advanced supportive care; it’s life-affirming care. It offers understanding, acceptance, and encouragement,” Yager said.

What’s more, palliative care may help protect patients from futile forced interventions, which can inflict trauma and shame, Yager said. “There’s some evidence that if families are really insistent, … treatment clinics and physicians are more inclined to impose coercion and involuntary treatment on patients.” By contrast, palliative care puts adult patients—rather than clinicians, the treatment facility, or even the family—in charge of their own care. However, he cautioned that this type of care alone should not be used for children, adolescents, or individuals who haven’t received high-quality, active treatment.