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Palliative psychiatry for severe and persistent mental illness



Sep 25, 2012
Planet Lunatic Asylum

Despite all of psychiatry's efforts to prevent mental illness and to promote recovery, some patients will develop severe and persistent mental illness (SMI). These patients represent a particularly vulnerable population, at risk of either therapeutic neglect or overly aggressive care. We propose a complementary approach in the treatment of SMI; palliative psychiatry, as a means to improve quality of care, person-centeredness, and autonomy for SMI patients.

Psychiatry and palliative care share common ground; both emerged from internal medicine, largely rely on the biopsychosocial model, and frequently operate in multiprofessional teams. Many patients receiving palliative care suffer from anxiety, depression, delirium, or other mental disorders. Consequently, the collaboration between the fields of psychiatry and palliative care has grown significantly over the last two decades,1 typically under the labels of palliative care psychiatry2 or psycho-oncology. By contrast, psychiatry does not explicitly provide palliative care for patients with mental illness, outside the context of medical illness.

Several clinical approaches in modern psychiatry can already be considered palliative, as they aim at promoting quality of life rather than achieving disease-remission or disease-modification. An example is maintenance heroin substitution, for which systematic evidence has been gathered through controlled trials.3 However, international consensus on indication for this palliative treatment is lacking. Another example for an arguably palliative situation in psychiatry is severe and enduring anorexia nervosa in which the decision is made to forego repeat hospitalisations with further cycles of involuntary refeeding.4 Such cases are controversial on a much more fundamental level: can we agree that there is fatal mental illness in those disorders for which our current treatment attempts are burdensome and ultimately futile?5

In our experience, cases of mental illness where futility is discussed inevitably divide the involved health care professionals, patients, and families. Psychiatry has no specific offer for these patients. There is no consensus on best practice, nor are there specialised services. Eventually, some of these patients receive palliative care and die in a medical setting.5 In the worst case scenario, care is determined by insurance coverage, with psychiatric care unavailable due to apparent lack of benefit and palliative care unavailable due to the apparent absence of a terminal illness. Patients themselves may be unable to press for a more palliative approach to their mental illness by virtue of their impaired decision-making capacity.

Although palliative psychiatry may not be a suitable approach for all patients with SMI, a substantial number of patients may benefit. We believe that psychiatry has much to gain from acknowledging the palliative nature of some of its interventions. We propose to develop palliative psychiatry as a new paradigm for the treatment of SMI with its own conceptual framework and clinical approach. Achieving consensus among psychiatrists and service users on the definition of SMI and the possibility for futility judgements in mental illness will be important milestones towards this goal.

We declare no competing interests.


Well-known member
Nov 23, 2015
OH bless their tiny stony black hearts.

The reason MY MI is worsening is because im not getting any treatment at all despite being in one of the most advanced medical cities in the world.

fucking morons. I live on the wrong side of town, theyre all over in the Posh Part. May as well be on Mars.