Severe Mental Illness and Palliative Medicine

Severe Mental Illness and Palliative Medicine

– Dr Suhana Sulfiker, New Delhi

A 50-year-old male, Vijay (name changed) with major depressive disorder had undergone various forms of psychotherapy and several trials of antidepressants and antipsychotic medications. He lives alone as he is separated from his wife. His children are married and live with their respective families. Despite all modalities of pharmacological and non-pharmacological treatments, his depression did not improve. He was also experiencing significant adverse effects of these medications. Exhausted and feeling hopeless, he chose to undergo electroconvulsive therapy, which unfortunately only worsened his symptoms. Vijay’s case illustrates the challenges of managing treatment-resistant depression and integration of palliative medicine.

Palliative care is dedicated to improving the quality of life for patients with life-limiting illnesses by addressing physical, emotional, social, and spiritual needs. When managing patients with severe mental illnesses (SMI), such as schizophrenia, bipolar disorder, major depressive disorder, and substance use disorders, palliative care must adopt a multidisciplinary approach that integrates psychiatric and palliative care strategies.

Types of Mental Disorders Relevant to Palliative Care

1. Anxiety and Depression
2. Affective (Mood) Disorders
3. Psychotic Disorders
4. Substance Use Disorders (SUD)
5. Post-Traumatic Stress Disorder (PTSD)

Psychiatric Illness in Palliative Care Practice

Patients with psychiatric illnesses in palliative care can present with:

• Pre-Existing Mental Health Issues: Conditions like generalized anxiety disorder, mild depression, or well-managed obsessive-compulsive disorder.
• Severe Mental Illnesses (SMI): Includes schizophrenia, bipolar disorder, severe major depressive disorder, and schizoaffective disorder.
• Adjustment Disorders: Significant impairments in functioning due to stressful or traumatic events when receiving palliative care.

The Emerging Field of Palliative Psychiatry

Palliative psychiatry is an emerging field focusing on mental health conditions that are severe and often unresponsive to traditional treatments. It emphasizes a comprehensive care approach, addressing ethical implications, therapeutic goals, and the balance between benefit and harm. This field aims to enhance the biopsychosocial-spiritual model of care, reducing stigma and improving the Quality of Life for patients with SMI.

In India, psychiatrists tend to support both curative and palliative approaches for patients with severe persistent mental illness (SPMI). However, there is hesitation in integrating palliative psychiatry due to its association with end-of-life care, and it being perceived as giving up or hopelessness.

Barriers to Integration of Palliative Medicine in SMI

The integration of palliative care in SMI management faces several barriers:

• Differences in professional practices between psychiatric and palliative care
• Stigma associated with both mental health conditions and end-of-life care
• Lack of resources and specialized services for this vulnerable group

The Way Forward

• Patient-Centered, Individualistic Care: Tailoring care plans to meet each patient’s unique needs
• Early Referral to Palliative Care: Ensuring timely interventions for patients with SMI
• Multidisciplinary Teams: Involving various healthcare professionals, such as nursing-home doctors, visiting geriatricians, social workers, psychiatrists, psychologists, community mental health nurses, and rehabilitation workers, to provide comprehensive care
• Collaboration with Community and Healthcare Services: Establishing partnerships to improve service delivery
• Advance Care Planning: Preparing for future health decisions and end-of-life care
• Capacity Building: Developing resources and training healthcare professionals to better manage SMI in palliative settings

In the case of Vijay, we realised that to effectively integrate Palliative Medicine, it was essential to enhance his quality of life by addressing the complex needs of physical, emotional, psychosocial, and spiritual domains. Adopting this approach would be transformative for Vijay as it would provide him with relief from the chronic distress and the associated suffering he was experiencing. We proceeded with holistic symptom management, psycho-socio-spiritual support, and advance care planning. We also spent time to learn and understand what his values were, and what mattered to him. These conversations also included understanding what he feared, and what he hoped for. Delivering personalised care allowed us to recognise that his life had meaning, even when various treatment options had not worked as expected. Integrating palliative care therefore helped Vijay and his loved ones navigate this difficult journey with dignity and with an improved quality of life.

In conclusion, patients with severe mental illness at the end of life are particularly vulnerable, with complex needs that are difficult to assess and meet. Close partnerships between mental health and end-of-life care systems are crucial to ensuring these patients receive the support they need, including enabling them to die where they choose. Addressing barriers, fostering collaboration, promoting shared decision-making, and building capacity are essential to improving the quality of life and care for patients with SMI in palliative settings.