- Severe persistent mental illnesses affect 1% of the population and are associated with substantial disability.
- Psychiatrists tend to focus treatment on symptom reduction, but some patients may not experience relief.
- Rehabilitative and palliative approaches may help such patients.
This post was written by Eugene Rubin MD, PhD and Charles Zorumski MD.
Individuals with severe persistent mental illness (SPMI) may suffer from a variety of illnesses including schizophrenia, bipolar disorder, anorexia nervosa, obsessive-compulsive disorder, or treatment-resistant depression. Individuals with these disorders suffer from chronic or frequently reoccurring symptoms that severely interfere with many aspects of daily life, including relationships, employment, and medical health. For such people, their quality of life is often poor.
Such disorders are not uncommon. In 2017, Harvey Whiteford and colleagues estimated that “3.3% of adults experience a severe mental illness each year, of whom one-third (1.1% of adults) experience a persistent mental illness that requires ongoing services to address residual disability.”
Psychiatrists try to help patients by employing treatments that attempt to eliminate or diminish symptoms. Treatments may include medications, psychotherapies, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagus nerve stimulation (VNS). However, symptoms associated with SPMI challenge psychiatrists’ therapeutic skills. Patients may be prescribed complicated regimens of medications and somatic interventions. Such regimens may help some individuals, but some patients end up on a large number of medications sometimes coupled with other treatments that may do more harm than good. Patients with complex illnesses are often admitted to academic inpatient settings where attending psychiatrists teach psychiatric trainees how to simplify complicated and potentially dangerous medication regimens and manage complex comorbid medical/neurological conditions.
Psychiatrists are trained to focus on symptomatic approaches to alleviate distress and dysfunction with the hope that these symptomatic treatments may be curative. They do not receive as much training in other ways to help improve the quality of life for individuals with SPMI. For example, rehabilitative-oriented approaches are designed to help individuals increase psychosocial skills that facilitate their ability to manage activities of daily living and interact with others in various settings like school or work. These approaches may involve collaboration with other health professionals such as occupational therapists.
In addition, there has been increased interest in applying palliative approaches to psychiatry. Many people are familiar with palliative approaches to improving quality of life during terminal illnesses. However, palliative medicine specialists not only target individuals during the end stages of life, but they also treat people with long-term, persistent illnesses. It would seem that patients with SPMI could benefit from similar approaches. In a 2016 article published in BMC Psychiatry, Manuel Trachsel and colleagues proposed the following working definition of palliative psychiatry: “Palliative psychiatry (PP) is an approach that improves the quality of life of patients and their families in facing the problems associated with life-threatening severe persistent mental illness (SPMI) through the prevention and relief of suffering by means of a timely assessment and treatment of associated physical, mental, social, and spiritual needs. PP focuses on harm reduction and on avoidance of the burden of some psychiatric interventions with questionable impact.”
A recent editorial in JAMA Psychiatry by Kwok Ying Chan and colleagues described some of the unique challenges of utilizing palliative techniques to help patients with SPMI. For instance, working with individuals who experience psychotic symptoms and thoughts of suicide can be challenging. The authors encourage collaboration between psychiatrists and specialists trained in palliative medicine. Each specialty has a knowledge base and specialized techniques that may be combined to help these patients.
Current psychiatric treatments are rarely, if ever, curative, particularly in patients with SPMI. We believe an emphasis on appropriate and thoughtful symptomatic treatments combined with rehabilitative therapies that focus on improving levels of psychosocial functioning and palliative approaches to enhance quality of life despite persistent symptoms should become mainstays of psychiatric treatment and training. This combination of approaches presently offers the best hope for improved outcomes in these challenging and complex disorders.
Whiteford, H., Buckingham, B., Harris, M., Diminic, S., Stockings, E., & Degenhardt, L. (2017). Estimating the number of adults with severe and persistent mental illness who have complex, multi-agency needs. Aust N Z J Psychiatry. 51(8):799-809.
Trachsel, M., Irwin, S.A., Biller-Andorno, N., Hoff, P., & Riese, F. (2016). Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks. BMC Psychiatry. 16:260.
Chan, K.Y., Yap, D.Y.H., & Gill, H.S.H. (2023). Rethinking palliative care in psychiatry. JAMA Psychiatry. 80(11):1089-1090.