April 22, 2025 • 30 mins
In this episode, Psychiatric News Editor-in-Chief Dr. Adrian Preda speaks with Dr. Anna Westermair, a psychiatrist and researcher whose work focuses on the emerging field of palliative psychiatry. Drawing on her recent Psychiatric News Special Report, Dr. Westermair offers a compelling case for considering quality of life—not just symptom remission—as a meaningful goal in treating individuals with severe and persistent mental illness (SPMI). Dr. Westermair emphasizes that palliative psychiatry is not about abandoning care—but about reframing goals to improve life meaningfully for patients often left behind by the traditional system.
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👉 Palliative Psychiatry: An Innovative Approach to Severe and Persistent Mental Illness
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PsychNews Special Report” is a production of Psychiatric News, a media platform dedicated to serving as the primary and most trusted source of information for APA members, other psychiatrists and physicians, health professionals, and the public about developments in the field of psychiatry and mental health that impact clinical care and professional practice. Learn more at psychiatryonline.org/journal/pn.
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(00:00):
you
Welcome to the Psychiatric News Special Report podcast, a monthly podcast from PsychiatricNews produced for the APA Medical Minds channel.
(00:20):
I'm Dr.
Adrian Preda, Editor-in-Chief of Psychiatric News and Professor of Clinical Psychiatry andHuman Behavior at University of California Irvine School of Medicine.
Each month, we sit down with the author or authors of our special report to dive into thekey themes, findings and real-world implications of their work.
Today, I'm joined by Dr.
(00:41):
Anna Westermeyer, an attending psychosomatic CL psychiatrist and senior research assistantat the Institute for Biomedical Research at the University of Zurich, based in
Switzerland, whose work explores the evolving field of palliative psychiatry.
Dr.
Westermeyer brings a unique international and cross-disciplinary perspective to theethical, clinical, and humanistic considerations that shape this topic.
(01:06):
We'll be discussing her special report,
published this month in Psychiatric News, which explores palliative psychiatry as analternative or complementary care model for individuals with severe and persistent mental
illness.
The article invites readers to reflect on how psychiatry defines treatment success andwhen relief from suffering and improving quality of life might be a more realistic and
(01:30):
humane goal than clinical recovery.
Anna, thank you for contributing your special report to Psychiatric News and
Thank you for joining us here today.
I wonder if we can start by you telling us a little about yourself, your career inpsychiatry and your interest in palliative psychiatry.
Yeah, sure.
Thanks so much for having me, Adrienne.
(01:51):
A bit about myself.
I studied medicine and psychology and then specialize in psychosomatic medicine andpalliative care, incidentally, which brought me to this kind of exotic research interest.
And when I started digging into that really new field, I soon realized this is first andforemost at the moment, an ethical question.
(02:14):
So we can't do RCTs in that, you know, very young field.
And that's why I decided to do a PhD in biomedical ethics on that topic.
And this is how I came to be where I am now.
I usually try and have both clinical and research duties, but right at the moment I'mtaking a break from clinical work because I have a position as mom now and that kind of
(02:37):
goes better together than a position as an attending.
Yes, well, this is a fascinating field, right?
And I think actually really informative for our listeners to start with, what ispalliative psychiatry?
Well, I guess right at the moment, palliative psychiatry is an idea.
It's the idea that it might be beneficial for our patients to introduce the generalapproach of palliative care to mental health care.
(03:06):
Is it different from the standard mental health care approaches for severe and persistentmental illness?
So the general idea in palliative psychiatry, it adopts the WHH definition of palliativecare, which stresses the importance of relieving suffering and improving quality of life.
(03:27):
Whereas by default, the goal of care, you know, in standard mental health care is symptomremission and improvement of psychosocial functioning.
So I guess in a nutshell, this is the difference, a shift in the primary goal of care.
You know, maybe we can spend a few moments there because in general, these goals tend tobe used maybe a little bit, you know, in a relaxed way when people talk about improvement.
(03:53):
What is it that that means?
Sometimes could mean clinical improvement.
At times could be a response versus recovery, which may or may not be related toimprovements in functioning or quality of life, right?
So how do you actually separate these different outcomes?
That's an interesting question.
Well, I guess at the moment we don't have as of yet validated instruments to reallymeasure quality of life in our patients halfway.
(04:22):
And I think this is definitely something that we need to develop with palliativepsychiatry is to become a part, you know, of more conventional mental health care.
quite sure whether you're referring to that, but feel free to.
Well, you know, you are answering the question here and actually you specify in yourarticle that first, know, there are differences between clinical improvement and quality
(04:47):
of life.
And maybe that's something that's not very intuitive in general when we think about thingsas clinicians, right?
We think that people improve clinically, well, that necessarily results in an improvementin quality of life.
And the point that you are making and the way I understand it, please correct me if I amwrong, is that
the emphasis in palliative psychiatry is actually on functioning, which may or may not becompletely related to clinical improvements in symptoms, right?
(05:13):
Yeah, yeah, yeah.
I think we're talking about the same thing.
So we wrote like a concept article on that two years ago, where we said that standard,know, standard, it's, you know, it's not meant in a negative way, but usually in mental
health care, we aim to reduce the symptoms that define a mental disorder.
(05:33):
So for example, hallucinations and schizophrenia, this will then lead to improvedpsychosocial functioning.
And this will then lead to
improved quality of life.
So this is why mental health care is a good thing, because indirectly it improves people'squality of life.
Then we have people where this sadly doesn't work, despite the best intentions ofeverybody, you know, that is being a part of that process.
(06:02):
And the idea of palliative psychiatry is maybe we can increase quality of life by means
other than reducing the core symptoms that define the mental illness.
It's like circumventing a mental disorder.
Yeah, and you know, one of the interesting questions there is, you so in general, probablyit's pretty straightforward, right?
(06:25):
We know that there is usually a pretty tight correlation between sort of clinicalimprovement first, which tends to result in improvement in functioning, which tends to
correlate with an improvement in quality of life.
But so one of the things that made me think when I was reading your article is thatactually that may not always be the case.
Well, that's probably the case most of the times.
(06:48):
And that's kind of the typical sort of medical paradigm, right?
We aim to treat things right because everything else gets better.
Sorry if I'm interrupting, but if that works, great!
Go for it!
Don't do palliative psychiatry!
Absolutely.
So palliative psychiatry, then maybe a way to think about it is when that doesn't work,then what?
(07:11):
And the palliative psychiatry perspective could have something else to offer to thatspecific patient subpopulation.
Yeah.
And those patients, so those are patients who tend to probably fall into the category ofpeople who have severe and persistent mental illness.
Can you just clarify what severe and persistent mental illness refers to?
(07:34):
Well, there is no consensus definition, sadly, but there is the 3D definition that I findvery useful.
obviously you need to have a diagnosis of a mental disorder, but it's not specified.
And theoretically, all mental disorders qualify.
And severe and persistent mental illness is more like a course that a disorder can take ina person in the sense that the duration, so in the sense that
(08:03):
the illness is present, the person is symptomatic for more than two years despite adequatetreatment.
And this results in a significant disability, meaning that there is an impairment ofpsychosocial functioning.
So this is the definition that I usually refer to when I talk about severe and persistentmental illness.
(08:26):
And yes, that's correct that, you know, the cases where we might think about palliativepsychiatry, they fall into that concept.
But it's important for me to stress that that doesn't mean that everybody who fulfills the3D criteria is a good candidate for palliative psychiatry.
It doesn't work that way around.
(08:46):
Yeah, that makes sense.
So diagnosis, so diagnosis is referring to severity and then duration and the longer theduration, probably the more chronic and persistent, right?
That's the persistent part of the of the criteria.
And then disability, these are the three days.
And to your point, then I think it's important to also consider the fact that not allsevere mental illness is necessarily persistent.
(09:12):
You could have a severe crisis and that's
that could be acute as opposed to chronic.
And also probably there are similarly, you know, cases where we could look at the chronicpersistent course of illness, which is not necessarily severe, right?
People can have a nicotine dependency for 30 years.
That's not necessarily a severe mental illness.
(09:35):
Right, that is very helpful.
In your report, you describe two very informative cases, and I think that maybe we can usethose cases to get a better sense of how palliative psychiatry assessments and
recommendations might be different than the typical course of care.
So could you walk us through one of the cases that could give our listeners a sense of theusefulness of this approach?
(10:00):
Yeah, sure.
Well, if it's okay, I would like to walk you through one of more or less a composite of myown cases because the cases in the report, I really do love them, but they were
contributed by my colleagues.
So I can't give you any more detail on those that is in the report.
imagine a patient who has been sick with anorexia nervosa for
(10:24):
25, 30 years had had multiple high quality treatments, but always sadly relapsed soonafterwards.
had a very low BMI for the last 10 years, couldn't work due to that low BMI, has a verydiminished life.
And she's now hospitalized with a BMI of around 10.
(10:50):
Obviously we...
recommended artificial nutrition to her, but she refused, which put us in a very difficultposition, as I guess some of you might know from their own experience.
And I sat down with this patient and tried to find a way to move forward together.
(11:11):
And what she told me was that she wanted to get better.
She didn't want to die, but she could not bear
being force fed again.
She had undergone that treatment a couple of times with little results, with littlebenefit.
So she couldn't be the thought of having artificial nutrition again.
(11:31):
And she told me if she were to get better, she needed to do it her own way and she neededto be in control.
And she told me she had only
enough energy left for one last push, for one last try.
She was really afraid she would end up like in a cycle of endless weight restoration andthen relapse and then weight restoration and then relapse.
(11:58):
And she needed to be assured that this would not happen.
So basically what she was asking was no artificial nutrition, even if she failed in herattempt to refeed herself orally.
and a DNR status.
So that was what she was requesting.
And well, you can imagine there was a very long decision process and a lot of people wereinvolved and it took some time.
(12:22):
But in the end, we granted her request and she got that in writing and she started eating.
She started eating and well, was not no walk in the park, but she managed to gain threeBMI points without any coercive measures.
went home and had a decent quality of life.
(12:43):
She could resume some of her leisure activities, so drawing was something that she enjoyedand she could do that again because she was able to stay upright for long enough to draw.
So I think we really, we accept the risk of her dying.
I think this is the palliative element of that approach and got a lot of quality of lifeout of that for her.
(13:08):
And well,
Obviously, there was not a miracle cure.
She relapsed a year later and came back in a terminal state.
But we had prepared for that.
Advanced care planning is also part of palliative care.
We had prepared for that.
She had a living will.
And we had had an independent attending a test to her capacity at that moment when shesigned that living will.
(13:33):
So sad as it was that she relapsed, when she came back, everything had already beendecided and we could really make her comfortable.
She was in a very quiet, friendly room.
was no heroic measures.
She died peacefully.
This is a really powerful and touching case.
(13:54):
And I think, you know, it does illustrate the importance of what you mentioned before,that it seems like, one of the principles that's foundational to palliative psychiatry is
the WHO model of care, which emphasizes prevention and relieving of suffering.
And it seems like that's kind of the point of the composite that you just presented forus.
(14:16):
Now, at the same time, these are situations that are really challenging for physicians tothink about prolonging life, right?
And end of life situations for most physicians tend to come at the price of high anxietyand really discomfort, right?
Because that's not how we are trained.
This is not how we think.
And there is a sense that when it comes to end of life, maybe there is always somethingelse that maybe could be done, or if not, things are hopeless.
(14:42):
There is this sense of hopelessness that tends to be associated with not
just palliative psychiatry, but palliative care in general, right?
It's another stage of care.
So as I'm sure that you are aware of, an alternative perspective on palliative psychiatryis that that's not the right way, the right way to think about helping these patients.
And why is that?
(15:02):
Because palliative evokes hopelessness, giving its origins in end-of-life care.
How do you respond to that?
Well, first of all, that's it's correct.
The term has some baggage.
Yeah, that's correct.
But also, I would like to stress that this is not, you know, specific for palliativepsychiatry.
(15:25):
This is something that palliative care in general struggles with the baggage of the term.
And there's even I think in Texas, there's a palliative care ward who exchanged the signsand they say now supportive care ward.
And so there's really a struggle to deal with the negative connotations that this termhas.
(15:48):
Personally, I find, you know, the alternative supportive kind of odd because, what isnon-supportive medicine?
I don't think that kind of works.
But, you know, on a more serious note, I kind of think it's a good thing that we have aterm with negative connotations because that
(16:10):
kind of acts as a barrier because if palliative psychiatry, you know, if we had like aterm that were, you know, very nice, something that everybody would want, something like
supportive psychiatry, I think that might be a danger.
And having a term that has some negative connotations can help us to pause before weemploy such a.
(16:38):
such an approach to not do it lightly, to not do it without being like really, really,really sure that this is what is best for this patient.
So in a way, the baggage could be seen as an opportunity to pause and reflect, which isimportant because there is qualitative, maybe that's a way to understand it, qualitative
(17:00):
change in the direction of care when we enter the palliative psychiatry realm.
Is that a way to understand it?
Yeah, I think so.
Which brings me to my next question, right?
Because these are patients who are in a different category.
there is, you mentioned that 3D, there is a clear understanding that there is severity,there is chronicity, persistence, and there is a high level of disability.
(17:25):
Now, when that happens, some would argue that there is no reason to think about palliativepsychiatry as a different approach.
We could just think about what good care for that type of specific clinical situations andpatients would entail.
which might be different than the typical clinical care recommendation.
in other words, the question is, isn't this, you know, for that specific cell populationof patients, the type of things that we're talking about, isn't that just good clinical
(17:52):
care?
What is different about palliative psychiatry that a good clinical, you know, care type oftreatment plan would not offer?
Yep, well, absolutely, Adrienne.
I'm glad if people think that what we are proposing is good clinical care because I verymuch think so too.
(18:12):
yeah, I absolutely agree with also the notion that this is what we have always done withthis type of patients.
Psychiatrists have always been confronted with people who do not benefit, do not reallybenefit from available treatments and they have found ways to cope with that.
It is my impression that each and every psychiatrist has had to find their own ways how tocope with that dilemma of wanting to help when what we have on offer does not really help.
(18:44):
We have hardly any research on how to relieve suffering, especially suffering from thesymptoms of mental disorder.
We have very little research on how to improve quality of life in people with severe andpersistent mental illness.
And I think one of the reasons for that is that we don't have a conceptual understandingand we don't value this approach enough.
(19:12):
It is something that we do, but we always feel like we're just muddling through because wedon't have a better idea and we don't necessarily teach that.
young psychiatrists.
Well, I can't speak about the US, but definitely in the German speaking countries, you aretaught a lot about guideline conformed treatment as you should be.
But then you start working or you're in your workplace and there's people who haveexhausted all guideline conformed treatment and basically nobody is telling you how can
(19:44):
you find a way forward with those patients.
I think to promote research into those important fields and to start developing trainingsfor young psychiatrists, I think we need to first define what we're talking about.
And this is why I think we need an explicitly defined concept.
(20:07):
What I hear you saying is that it would be great if that would be the standard of care,but the reality of medical care for a variety of reasons, but a significant component here
is that as physicians, we are trained to improve clinical outcomes based on evidence-baseddata that is quantifying clinical outcomes as opposed to suffering or quality of life.
(20:31):
So it's almost like, know, physicians, it's the nature of things maybe.
We tend to be wired through training, through experiences, towards looking at clinicaloutcomes first, as opposed to quality of life.
And these things, yes, they are correlated, but not always.
And what palliative care offers that's different is really that very heavy emphasis on thequality of life, which I would agree with you.
(20:57):
I think that that should be part of considerations of clinical care all along, but evenmore so
in the type of situations that we see with our SPMI patients.
And the other part that I think that seems like it's implicit in this, and I love the casethat you presented, probably some cultural differences, but I think it's still true that
(21:19):
all over the world, physicians, the physician-patient relationship tends to still be tosome extent somewhat paternalistic.
in which physicians tend to make the decisions, they could share them with the patients,we ask for agreement, we make sure that everybody's on the same page.
But the physician is the driving force between the decision as opposed to a truly sort ofco-shared decision making, which seems to be at the core of palliative psychiatry.
(21:45):
Is that a fair thing to say?
At least I do hope that palliative psychiatry promotes a more partnership form ofpatient-psychiatrist relationship.
And I think the ethical thinking behind that is that even if people lack decision-makingcapacity, and a lot of the people that palliative psychiatry is about do not have
(22:15):
decision-making capacity, or at least not.
enough to simply respect their wishes.
But even if they do not have decision-making capacity, being subjected to coercion or notbeing listened to is burdensome to them.
So I think what I'm trying to say is even if we're not obligated to respect their wishesbecause they don't have decision-making capacity.
(22:41):
I believe that we still have like an obligation from the principle of non-maleficence toinvolve them as much as possible in the decision making.
Yeah.
And you know, in your article, you also mentioned something that I think it's veryimportant to consider.
You talk about this sense of learned hopelessness could occur with repeated treatmentfailures.
(23:05):
And we know that cross-diagnostically, unfortunately, we have a good number of ourpatients who eventually meet criteria for treatment resistance, meaning they have tried
multiple treatments in the prescribed way.
doses of medications for the recommended amount of time sent yet they do not improve.
And I think an important point there to consider is how does the number of the treatmentfailures could in fact increase the risk for learning helplessness, which could increase
(23:39):
the risk for mood problems and depression farther down the road.
I realize there is no data on that, but I think there is a very, very important
point to consider.
And it sounds like from a palliative psychiatry perspective, one of the things that youwould consider is to find a way to alleviate some of that sense of home homelessness
(24:02):
because you are bringing the patient on board.
You are giving them a real authority in making some of these very important decisions thattraditionally when people go for involuntary treatments tend to be taken away from the
patient.
Yeah.
And also what we wanted to convey here is that trying yet another treatment, it alwayscomes with the side effect of exposing the patient to the risk of experiencing another
(24:37):
treatment failure.
So I think there's a risk benefit analysis to do here.
And obviously we always have the hope that the next
treatment attempt will result in clinical remission or at least partial clinicalremission.
But I think we have to be mindful about there always being a price to pay for the patientin terms of false hopes or not false hopes, but hopes that result in disillusionment.
(25:09):
So we've been talking about opportunities, right, and the complementary and improvement inoverall care of our patients that palliative psychiatry could bring to the table.
What about challenges?
What about limitations?
there are so many.
Well, obviously, right now, it's just, it's an idea.
(25:31):
It's a concept.
Yeah, it's not, you know, it's not a flashed out ready to implement approach.
Obviously, I think there's a lot of research that's left to do.
And I think one one important pitfall that we have to be very mindful of is that it mightcome across as as giving up.
(25:53):
There's actually a couple of articles against palliative approaches that are entitled, weshouldn't give patients up.
And well, obviously this is not what we are meaning with that, but I understand where thatassociation comes from.
And I do believe that there's a risk of misuse.
(26:14):
I think we have to be very, very honest with ourselves if we're considering a palliativeapproach.
Why we're considering that?
Are we considering that because we honestly feel it might be better for the patient or arewe considering it because we are annoyed or frustrated or bored or I don't know, anything
(26:37):
else.
So I think we have to be very honest with ourselves here.
And I also think that we should never decide upon a palliative approach alone.
This should always be part.
of a multi-professional, multi-disciplinary decision-making process that obviously alsoinvolves the patient and their significant others and clinical ethics.
(27:01):
so there's always a group, a room full of people once these decisions are made.
And I think that's right now when palliative psychiatry is, I think we have to say it's anexperimental treatment because we don't have good evidence to prove its effectiveness and
efficiency.
Yeah, I think that's the way to go.
(27:23):
Really reasoned.
is really...
Yeah, These are important points.
in your article, you also discuss and you're touching on that.
There is a risk here that this approach could unintentionally reinforce the stigmatizationof people with severe mental disorders.
And you say, you know, that shouldn't result in people being seen as hopeless cases andnot worth being cared for.
(27:47):
So that's a real concern.
And then it's important to be acknowledged.
Absolutely.
And I think what's important to keep in mind is what I always discuss with patients inpalliative care, so people with life-limiting somatic illnesses.
I think we have to differentiate hope because there's always hope.
It's just that in some situations it may be wise to change what we hope for, not that wehope at all.
(28:14):
I think hope is a genuine human feature.
There's simply a shift in maybe not hoping for complete mental and physical well-beinganymore, but hoping for more good days than bad days or hoping for finding a friend,
(28:36):
something like that.
There is always hope and I think this is very, very, important that we stress that,especially with patients who might be considered eligible for palliative psychiatry.
And I think that's such an important point and it is important, I think, to emphasize thatwhat he does on the surface appears to be hopelessness or hopeless.
(28:59):
In fact, this is approach to restore some of that hope that's been maybe taken away.
Absolutely, because if we shift the priority from an unrealistic goal, the goal ofclinical remission, full clinical remission, which in some cases sadly is unrealistic,
then we can focus something that we might well achieve, something that will trulycontribute to the well-being of the person that is sitting in front of us.
(29:30):
It may not be as grand as health.
but it may still help them live a meaningful life.
And yeah, you're right.
I actually think that paleotropsy could, you bring hope, but you have to think a bit aboutit before you can see it like.
Anna, thank you so much for a thoughtful and illuminating discussion.
(29:51):
And thanks to all of you for listening to the Psychiatric News Special Report podcast.
You can read Dr.
Westheimer's full Psychiatric News Special Report at psychnews.org.
We've posted a link to the article in the episode description.
If you enjoyed today's episode, please take a moment to subscribe, rate, and review thepodcast.
It helps others discover these important conversations.
(30:14):
You can find all episodes on APS Medical Minds channel and on the Psychiatric Newswebsite.
And don't forget to share this episode with colleagues and friends who might find itmeaningful.
We'll be back soon with more expert conversation.
Until then, stay informed, stay compassionate, and take care.
you
you
Welcome to the Psychiatric News Special Report podcast, a monthly podcast from PsychiatricNews produced for the APA Medical Minds channel.
(00:20):
I'm Dr.
Adrian Preda, Editor-in-Chief of Psychiatric News and Professor of Clinical Psychiatry andHuman Behavior at University of California Irvine School of Medicine.
Each month, we sit down with the author or authors of our special report to dive into thekey themes, findings and real-world implications of their work.
Today, I'm joined by Dr.
(00:41):
Anna Westermeyer, an attending psychosomatic CL psychiatrist and senior research assistantat the Institute for Biomedical Research at the University of Zurich, based in
Switzerland, whose work explores the evolving field of palliative psychiatry.
Dr.
Westermeyer brings a unique international and cross-disciplinary perspective to theethical, clinical, and humanistic considerations that shape this topic.
(01:06):
We'll be discussing her special report,
published this month in Psychiatric News, which explores palliative psychiatry as analternative or complementary care model for individuals with severe and persistent mental
illness.
The article invites readers to reflect on how psychiatry defines treatment success andwhen relief from suffering and improving quality of life might be a more realistic and
(01:30):
humane goal than clinical recovery.
Anna, thank you for contributing your special report to Psychiatric News and
Thank you for joining us here today.
I wonder if we can start by you telling us a little about yourself, your career inpsychiatry and your interest in palliative psychiatry.
Yeah, sure.
Thanks so much for having me, Adrienne.
(01:51):
A bit about myself.
I studied medicine and psychology and then specialize in psychosomatic medicine andpalliative care, incidentally, which brought me to this kind of exotic research interest.
And when I started digging into that really new field, I soon realized this is first andforemost at the moment, an ethical question.
(02:14):
So we can't do RCTs in that, you know, very young field.
And that's why I decided to do a PhD in biomedical ethics on that topic.
And this is how I came to be where I am now.
I usually try and have both clinical and research duties, but right at the moment I'mtaking a break from clinical work because I have a position as mom now and that kind of
(02:37):
goes better together than a position as an attending.
Yes, well, this is a fascinating field, right?
And I think actually really informative for our listeners to start with, what ispalliative psychiatry?
Well, I guess right at the moment, palliative psychiatry is an idea.
It's the idea that it might be beneficial for our patients to introduce the generalapproach of palliative care to mental health care.
(03:06):
Is it different from the standard mental health care approaches for severe and persistentmental illness?
So the general idea in palliative psychiatry, it adopts the WHH definition of palliativecare, which stresses the importance of relieving suffering and improving quality of life.
(03:27):
Whereas by default, the goal of care, you know, in standard mental health care is symptomremission and improvement of psychosocial functioning.
So I guess in a nutshell, this is the difference, a shift in the primary goal of care.
You know, maybe we can spend a few moments there because in general, these goals tend tobe used maybe a little bit, you know, in a relaxed way when people talk about improvement.
(03:53):
What is it that that means?
Sometimes could mean clinical improvement.
At times could be a response versus recovery, which may or may not be related toimprovements in functioning or quality of life, right?
So how do you actually separate these different outcomes?
That's an interesting question.
Well, I guess at the moment we don't have as of yet validated instruments to reallymeasure quality of life in our patients halfway.
(04:22):
And I think this is definitely something that we need to develop with palliativepsychiatry is to become a part, you know, of more conventional mental health care.
quite sure whether you're referring to that, but feel free to.
Well, you know, you are answering the question here and actually you specify in yourarticle that first, know, there are differences between clinical improvement and quality
(04:47):
of life.
And maybe that's something that's not very intuitive in general when we think about thingsas clinicians, right?
We think that people improve clinically, well, that necessarily results in an improvementin quality of life.
And the point that you are making and the way I understand it, please correct me if I amwrong, is that
the emphasis in palliative psychiatry is actually on functioning, which may or may not becompletely related to clinical improvements in symptoms, right?
(05:13):
Yeah, yeah, yeah.
I think we're talking about the same thing.
So we wrote like a concept article on that two years ago, where we said that standard,know, standard, it's, you know, it's not meant in a negative way, but usually in mental
health care, we aim to reduce the symptoms that define a mental disorder.
(05:33):
So for example, hallucinations and schizophrenia, this will then lead to improvedpsychosocial functioning.
And this will then lead to
improved quality of life.
So this is why mental health care is a good thing, because indirectly it improves people'squality of life.
Then we have people where this sadly doesn't work, despite the best intentions ofeverybody, you know, that is being a part of that process.
(06:02):
And the idea of palliative psychiatry is maybe we can increase quality of life by means
other than reducing the core symptoms that define the mental illness.
It's like circumventing a mental disorder.
Yeah, and you know, one of the interesting questions there is, you so in general, probablyit's pretty straightforward, right?
(06:25):
We know that there is usually a pretty tight correlation between sort of clinicalimprovement first, which tends to result in improvement in functioning, which tends to
correlate with an improvement in quality of life.
But so one of the things that made me think when I was reading your article is thatactually that may not always be the case.
Well, that's probably the case most of the times.
(06:48):
And that's kind of the typical sort of medical paradigm, right?
We aim to treat things right because everything else gets better.
Sorry if I'm interrupting, but if that works, great!
Go for it!
Don't do palliative psychiatry!
Absolutely.
So palliative psychiatry, then maybe a way to think about it is when that doesn't work,then what?
(07:11):
And the palliative psychiatry perspective could have something else to offer to thatspecific patient subpopulation.
Yeah.
And those patients, so those are patients who tend to probably fall into the category ofpeople who have severe and persistent mental illness.
Can you just clarify what severe and persistent mental illness refers to?
(07:34):
Well, there is no consensus definition, sadly, but there is the 3D definition that I findvery useful.
obviously you need to have a diagnosis of a mental disorder, but it's not specified.
And theoretically, all mental disorders qualify.
And severe and persistent mental illness is more like a course that a disorder can take ina person in the sense that the duration, so in the sense that
(08:03):
the illness is present, the person is symptomatic for more than two years despite adequatetreatment.
And this results in a significant disability, meaning that there is an impairment ofpsychosocial functioning.
So this is the definition that I usually refer to when I talk about severe and persistentmental illness.
(08:26):
And yes, that's correct that, you know, the cases where we might think about palliativepsychiatry, they fall into that concept.
But it's important for me to stress that that doesn't mean that everybody who fulfills the3D criteria is a good candidate for palliative psychiatry.
It doesn't work that way around.
(08:46):
Yeah, that makes sense.
So diagnosis, so diagnosis is referring to severity and then duration and the longer theduration, probably the more chronic and persistent, right?
That's the persistent part of the of the criteria.
And then disability, these are the three days.
And to your point, then I think it's important to also consider the fact that not allsevere mental illness is necessarily persistent.
(09:12):
You could have a severe crisis and that's
that could be acute as opposed to chronic.
And also probably there are similarly, you know, cases where we could look at the chronicpersistent course of illness, which is not necessarily severe, right?
People can have a nicotine dependency for 30 years.
That's not necessarily a severe mental illness.
(09:35):
Right, that is very helpful.
In your report, you describe two very informative cases, and I think that maybe we can usethose cases to get a better sense of how palliative psychiatry assessments and
recommendations might be different than the typical course of care.
So could you walk us through one of the cases that could give our listeners a sense of theusefulness of this approach?
(10:00):
Yeah, sure.
Well, if it's okay, I would like to walk you through one of more or less a composite of myown cases because the cases in the report, I really do love them, but they were
contributed by my colleagues.
So I can't give you any more detail on those that is in the report.
imagine a patient who has been sick with anorexia nervosa for
(10:24):
25, 30 years had had multiple high quality treatments, but always sadly relapsed soonafterwards.
had a very low BMI for the last 10 years, couldn't work due to that low BMI, has a verydiminished life.
And she's now hospitalized with a BMI of around 10.
(10:50):
Obviously we...
recommended artificial nutrition to her, but she refused, which put us in a very difficultposition, as I guess some of you might know from their own experience.
And I sat down with this patient and tried to find a way to move forward together.
(11:11):
And what she told me was that she wanted to get better.
She didn't want to die, but she could not bear
being force fed again.
She had undergone that treatment a couple of times with little results, with littlebenefit.
So she couldn't be the thought of having artificial nutrition again.
(11:31):
And she told me if she were to get better, she needed to do it her own way and she neededto be in control.
And she told me she had only
enough energy left for one last push, for one last try.
She was really afraid she would end up like in a cycle of endless weight restoration andthen relapse and then weight restoration and then relapse.
(11:58):
And she needed to be assured that this would not happen.
So basically what she was asking was no artificial nutrition, even if she failed in herattempt to refeed herself orally.
and a DNR status.
So that was what she was requesting.
And well, you can imagine there was a very long decision process and a lot of people wereinvolved and it took some time.
(12:22):
But in the end, we granted her request and she got that in writing and she started eating.
She started eating and well, was not no walk in the park, but she managed to gain threeBMI points without any coercive measures.
went home and had a decent quality of life.
(12:43):
She could resume some of her leisure activities, so drawing was something that she enjoyedand she could do that again because she was able to stay upright for long enough to draw.
So I think we really, we accept the risk of her dying.
I think this is the palliative element of that approach and got a lot of quality of lifeout of that for her.
(13:08):
And well,
Obviously, there was not a miracle cure.
She relapsed a year later and came back in a terminal state.
But we had prepared for that.
Advanced care planning is also part of palliative care.
We had prepared for that.
She had a living will.
And we had had an independent attending a test to her capacity at that moment when shesigned that living will.
(13:33):
So sad as it was that she relapsed, when she came back, everything had already beendecided and we could really make her comfortable.
She was in a very quiet, friendly room.
was no heroic measures.
She died peacefully.
This is a really powerful and touching case.
(13:54):
And I think, you know, it does illustrate the importance of what you mentioned before,that it seems like, one of the principles that's foundational to palliative psychiatry is
the WHO model of care, which emphasizes prevention and relieving of suffering.
And it seems like that's kind of the point of the composite that you just presented forus.
(14:16):
Now, at the same time, these are situations that are really challenging for physicians tothink about prolonging life, right?
And end of life situations for most physicians tend to come at the price of high anxietyand really discomfort, right?
Because that's not how we are trained.
This is not how we think.
And there is a sense that when it comes to end of life, maybe there is always somethingelse that maybe could be done, or if not, things are hopeless.
(14:42):
There is this sense of hopelessness that tends to be associated with not
just palliative psychiatry, but palliative care in general, right?
It's another stage of care.
So as I'm sure that you are aware of, an alternative perspective on palliative psychiatryis that that's not the right way, the right way to think about helping these patients.
And why is that?
(15:02):
Because palliative evokes hopelessness, giving its origins in end-of-life care.
How do you respond to that?
Well, first of all, that's it's correct.
The term has some baggage.
Yeah, that's correct.
But also, I would like to stress that this is not, you know, specific for palliativepsychiatry.
(15:25):
This is something that palliative care in general struggles with the baggage of the term.
And there's even I think in Texas, there's a palliative care ward who exchanged the signsand they say now supportive care ward.
And so there's really a struggle to deal with the negative connotations that this termhas.
(15:48):
Personally, I find, you know, the alternative supportive kind of odd because, what isnon-supportive medicine?
I don't think that kind of works.
But, you know, on a more serious note, I kind of think it's a good thing that we have aterm with negative connotations because that
(16:10):
kind of acts as a barrier because if palliative psychiatry, you know, if we had like aterm that were, you know, very nice, something that everybody would want, something like
supportive psychiatry, I think that might be a danger.
And having a term that has some negative connotations can help us to pause before weemploy such a.
(16:38):
such an approach to not do it lightly, to not do it without being like really, really,really sure that this is what is best for this patient.
So in a way, the baggage could be seen as an opportunity to pause and reflect, which isimportant because there is qualitative, maybe that's a way to understand it, qualitative
(17:00):
change in the direction of care when we enter the palliative psychiatry realm.
Is that a way to understand it?
Yeah, I think so.
Which brings me to my next question, right?
Because these are patients who are in a different category.
there is, you mentioned that 3D, there is a clear understanding that there is severity,there is chronicity, persistence, and there is a high level of disability.
(17:25):
Now, when that happens, some would argue that there is no reason to think about palliativepsychiatry as a different approach.
We could just think about what good care for that type of specific clinical situations andpatients would entail.
which might be different than the typical clinical care recommendation.
in other words, the question is, isn't this, you know, for that specific cell populationof patients, the type of things that we're talking about, isn't that just good clinical
(17:52):
care?
What is different about palliative psychiatry that a good clinical, you know, care type oftreatment plan would not offer?
Yep, well, absolutely, Adrienne.
I'm glad if people think that what we are proposing is good clinical care because I verymuch think so too.
(18:12):
yeah, I absolutely agree with also the notion that this is what we have always done withthis type of patients.
Psychiatrists have always been confronted with people who do not benefit, do not reallybenefit from available treatments and they have found ways to cope with that.
It is my impression that each and every psychiatrist has had to find their own ways how tocope with that dilemma of wanting to help when what we have on offer does not really help.
(18:44):
We have hardly any research on how to relieve suffering, especially suffering from thesymptoms of mental disorder.
We have very little research on how to improve quality of life in people with severe andpersistent mental illness.
And I think one of the reasons for that is that we don't have a conceptual understandingand we don't value this approach enough.
(19:12):
It is something that we do, but we always feel like we're just muddling through because wedon't have a better idea and we don't necessarily teach that.
young psychiatrists.
Well, I can't speak about the US, but definitely in the German speaking countries, you aretaught a lot about guideline conformed treatment as you should be.
But then you start working or you're in your workplace and there's people who haveexhausted all guideline conformed treatment and basically nobody is telling you how can
(19:44):
you find a way forward with those patients.
I think to promote research into those important fields and to start developing trainingsfor young psychiatrists, I think we need to first define what we're talking about.
And this is why I think we need an explicitly defined concept.
(20:07):
What I hear you saying is that it would be great if that would be the standard of care,but the reality of medical care for a variety of reasons, but a significant component here
is that as physicians, we are trained to improve clinical outcomes based on evidence-baseddata that is quantifying clinical outcomes as opposed to suffering or quality of life.
(20:31):
So it's almost like, know, physicians, it's the nature of things maybe.
We tend to be wired through training, through experiences, towards looking at clinicaloutcomes first, as opposed to quality of life.
And these things, yes, they are correlated, but not always.
And what palliative care offers that's different is really that very heavy emphasis on thequality of life, which I would agree with you.
(20:57):
I think that that should be part of considerations of clinical care all along, but evenmore so
in the type of situations that we see with our SPMI patients.
And the other part that I think that seems like it's implicit in this, and I love the casethat you presented, probably some cultural differences, but I think it's still true that
(21:19):
all over the world, physicians, the physician-patient relationship tends to still be tosome extent somewhat paternalistic.
in which physicians tend to make the decisions, they could share them with the patients,we ask for agreement, we make sure that everybody's on the same page.
But the physician is the driving force between the decision as opposed to a truly sort ofco-shared decision making, which seems to be at the core of palliative psychiatry.
(21:45):
Is that a fair thing to say?
At least I do hope that palliative psychiatry promotes a more partnership form ofpatient-psychiatrist relationship.
And I think the ethical thinking behind that is that even if people lack decision-makingcapacity, and a lot of the people that palliative psychiatry is about do not have
(22:15):
decision-making capacity, or at least not.
enough to simply respect their wishes.
But even if they do not have decision-making capacity, being subjected to coercion or notbeing listened to is burdensome to them.
So I think what I'm trying to say is even if we're not obligated to respect their wishesbecause they don't have decision-making capacity.
(22:41):
I believe that we still have like an obligation from the principle of non-maleficence toinvolve them as much as possible in the decision making.
Yeah.
And you know, in your article, you also mentioned something that I think it's veryimportant to consider.
You talk about this sense of learned hopelessness could occur with repeated treatmentfailures.
(23:05):
And we know that cross-diagnostically, unfortunately, we have a good number of ourpatients who eventually meet criteria for treatment resistance, meaning they have tried
multiple treatments in the prescribed way.
doses of medications for the recommended amount of time sent yet they do not improve.
And I think an important point there to consider is how does the number of the treatmentfailures could in fact increase the risk for learning helplessness, which could increase
(23:39):
the risk for mood problems and depression farther down the road.
I realize there is no data on that, but I think there is a very, very important
point to consider.
And it sounds like from a palliative psychiatry perspective, one of the things that youwould consider is to find a way to alleviate some of that sense of home homelessness
(24:02):
because you are bringing the patient on board.
You are giving them a real authority in making some of these very important decisions thattraditionally when people go for involuntary treatments tend to be taken away from the
patient.
Yeah.
And also what we wanted to convey here is that trying yet another treatment, it alwayscomes with the side effect of exposing the patient to the risk of experiencing another
(24:37):
treatment failure.
So I think there's a risk benefit analysis to do here.
And obviously we always have the hope that the next
treatment attempt will result in clinical remission or at least partial clinicalremission.
But I think we have to be mindful about there always being a price to pay for the patientin terms of false hopes or not false hopes, but hopes that result in disillusionment.
(25:09):
So we've been talking about opportunities, right, and the complementary and improvement inoverall care of our patients that palliative psychiatry could bring to the table.
What about challenges?
What about limitations?
there are so many.
Well, obviously, right now, it's just, it's an idea.
(25:31):
It's a concept.
Yeah, it's not, you know, it's not a flashed out ready to implement approach.
Obviously, I think there's a lot of research that's left to do.
And I think one one important pitfall that we have to be very mindful of is that it mightcome across as as giving up.
(25:53):
There's actually a couple of articles against palliative approaches that are entitled, weshouldn't give patients up.
And well, obviously this is not what we are meaning with that, but I understand where thatassociation comes from.
And I do believe that there's a risk of misuse.
(26:14):
I think we have to be very, very honest with ourselves if we're considering a palliativeapproach.
Why we're considering that?
Are we considering that because we honestly feel it might be better for the patient or arewe considering it because we are annoyed or frustrated or bored or I don't know, anything
(26:37):
else.
So I think we have to be very honest with ourselves here.
And I also think that we should never decide upon a palliative approach alone.
This should always be part.
of a multi-professional, multi-disciplinary decision-making process that obviously alsoinvolves the patient and their significant others and clinical ethics.
(27:01):
so there's always a group, a room full of people once these decisions are made.
And I think that's right now when palliative psychiatry is, I think we have to say it's anexperimental treatment because we don't have good evidence to prove its effectiveness and
efficiency.
Yeah, I think that's the way to go.
(27:23):
Really reasoned.
is really...
Yeah, These are important points.
in your article, you also discuss and you're touching on that.
There is a risk here that this approach could unintentionally reinforce the stigmatizationof people with severe mental disorders.
And you say, you know, that shouldn't result in people being seen as hopeless cases andnot worth being cared for.
(27:47):
So that's a real concern.
And then it's important to be acknowledged.
Absolutely.
And I think what's important to keep in mind is what I always discuss with patients inpalliative care, so people with life-limiting somatic illnesses.
I think we have to differentiate hope because there's always hope.
It's just that in some situations it may be wise to change what we hope for, not that wehope at all.
(28:14):
I think hope is a genuine human feature.
There's simply a shift in maybe not hoping for complete mental and physical well-beinganymore, but hoping for more good days than bad days or hoping for finding a friend,
(28:36):
something like that.
There is always hope and I think this is very, very, important that we stress that,especially with patients who might be considered eligible for palliative psychiatry.
And I think that's such an important point and it is important, I think, to emphasize thatwhat he does on the surface appears to be hopelessness or hopeless.
(28:59):
In fact, this is approach to restore some of that hope that's been maybe taken away.
Absolutely, because if we shift the priority from an unrealistic goal, the goal ofclinical remission, full clinical remission, which in some cases sadly is unrealistic,
then we can focus something that we might well achieve, something that will trulycontribute to the well-being of the person that is sitting in front of us.
(29:30):
It may not be as grand as health.
but it may still help them live a meaningful life.
And yeah, you're right.
I actually think that paleotropsy could, you bring hope, but you have to think a bit aboutit before you can see it like.
Anna, thank you so much for a thoughtful and illuminating discussion.
(29:51):
And thanks to all of you for listening to the Psychiatric News Special Report podcast.
You can read Dr.
Westheimer's full Psychiatric News Special Report at psychnews.org.
We've posted a link to the article in the episode description.
If you enjoyed today's episode, please take a moment to subscribe, rate, and review thepodcast.
It helps others discover these important conversations.
(30:14):
You can find all episodes on APS Medical Minds channel and on the Psychiatric Newswebsite.
And don't forget to share this episode with colleagues and friends who might find itmeaningful.
We'll be back soon with more expert conversation.
Until then, stay informed, stay compassionate, and take care.
you
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