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I read two articles in the October issue of Clinical Psychiatry News, and would like to share the reads and my take on both.

First by Jennie Smith, the cover story “Palliative Care Reimagined”, talking about a new approach to dealing with what the author calls “severe persistent mental illness (SPMI in the article)”.

http://www.mdedge.com/clinicalpsychiatrynews/article/147434/schizophrenia-other-psychotic-disorders/palliative-care

Several comments in there to digest:

“Neither Dr. Trachsel’s survey respondents nor those who attended his presentation seemed comfortable with the idea of extending the term “palliative care” – which is often and incorrectly associated with well-defined end-of-life scenarios – to serious, treatment-refractory mental illness. In those illnesses, disease trajectories may be less certain and futility is harder to define. They and other clinicians, however, did voice general support for the underlying concepts of promoting quality of life and decision-making autonomy for patients with SPMI, as well as palliative care targeted at the medical illnesses often acquired by those with SPMI.

According to Dr. Irwin and Dr. Lapid, reducing symptoms, acknowledging that there is no cure for SPMI, and focusing on optimizing patients’ quality of life would be core components of palliative care.”

Note in the second paragraph the key wording, “there is no cure for SPMI”, and that is quite the comment to write in a psychiatric article, as doctors while saying outright there are no cures, well, we do act like we can provide them at the end of the day, eh?

Certainly with the way psychiatrists write for polypharmacy like it is the second coming of Christ, well, what is that agenda about, folks?!  Makes you wonder if we are, to a degree, prescribing chemotherapy for some patients??

Further on, “Patients with SPMI die 25 years earlier than do their peers without SPMI. Most of the premature mortality associated with SPMI, which cuts across age groups, is attributable to chronic diseases rather than to violence or suicide. Less overall engagement with the health care system, leading to late treatment or undertreatment of disease, is one explanation for the premature mortality found among some people in this demographic. 

In addition, studies have shown that individuals with SPMI have less access to palliative and hospice care. One study, for example, found that people with schizophrenia and a terminal illness went into hospice half as often as did people without SPMI (Schizophr Res. 2012 Nov;141:241-6). In a recent editorial, a team of psychiatrists and pain specialists called such disparities “unacceptable” and demanded cross-collaboration to resolve them (Gen Hospital Psych. 2017 Jan-Feb;44:1-3).

Dr. Lapid said one reason people with SPMI – with or without a life-limiting comorbidity – end up with less access to palliative and hospice care is that “the art of what we do in hospice and palliative care, advanced planning – is not something we do well or routinely in psychiatry.”

Hmm, maybe some of my colleagues are beginning to realize that we can’t save every single person who comes to our attention, especially the ones forced into treatment.  While I NEVER give up on anyone who wants, even if a trivial amount, some intervention for care, there are people I have met in my travels who I have to honestly, and painfully admit, are not going to make it in society.  NOT advocating for premature death or euthanasia, but, advanced care services really have altered the natural selection process, and how much has health care really made responsible and appropriate strides to help the population as a whole?

Yes, that last sentence is quite the comment, but, it has to be said, and this article I have linked is probably going to have the load of responses by colleagues in upcoming issues.  For me, this post is my reply, and I can only hope some psychiatrists might take a little pause and wonder, however briefly before discarded, are patients really benefiting from full court presses for years, giving treatments that have as much risks as benefits??

The article ends with this:

“The approach used by psychiatrists treating patients with SPMI is very palliative in approach, Dr. Irwin and Dr. Lapid said. Psychiatrists reduce symptoms and acknowledge that SPMIs are chronic diseases for which there is no cure. To palliate is to make comfortable, to reduce symptoms, to reduce distress and pain, and to relieve suffering and optimize quality of life.

“In cancer, we’ve been telling people for 30 years, ‘keep fighting, because tomorrow there could be a new cure.’ But there’ve been very few new cures,” Dr. Irwin said. “And while some people want to fight to the end in case that cure comes, there are many who would have rather known that there really was little chance and might have made different choices.” In psychiatry, for psychiatric illnesses, he continued, “we need to really start thinking about the course of a person’s life, their quality of life, and the likelihood that they will get better or meet their goals, and what is a tolerable symptom burden for them. Because in the end, these questions apply to all patients.”

Not easy situations to ponder and approach, but, the term “quality of care” is something I hear less of in psychiatric circles of late, and that really bothers me, because life is about quality first, quantity second.

Anyway, to the second article, somewhat related to the first, is by Nicolas Badre MD, “Ethics in compulsory treatment of patients with severe mental illness”.

http://www.mdedge.com/clinicalpsychiatrynews/article/146823/schizophrenia-other-psychotic-disorders/ethics-compulsory

I am not going to duplicate much from this article, but, I found the assessment by Dr Badre to possibly miss a very valid alternative diagnostic option, that being George might have in fact a Personality Disorder, perhaps Paranoid or Schizoid P. D/O.  At least the doctor did not press meds, and the outcome of this man’s stay in correctional services seemed less harsh and punitive than it could have been.

At the end Dr Badre writes, “George reminds me that life, including schizophrenia, is more interesting and complicated than a set of genes, pathways, neurons, or neurotransmitters. Our patients’ lives may be convoluted with delusions, often stemming from truth or impaired affects, which are nonetheless genuine. I don’t know what will happen to George, but his past 50 years suggest that he will continue to have friends, and he will continue to live without being impaired by his delusions. Strangely, I worry less about him than many of my other patients.

Many mental health providers have advocated for a wider and easier access to involuntarily medicate our patients. I think that there is a misguided belief that involuntary antipsychotic treatment will lead to a rise in their use. However, if Carl Rogers, PhD, and others were right in stating that our relationship with our patients was the ultimate factor in their recovery, at what cost are we willing to jeopardize this? My fear is that this cost will be the loss of trust, which is so necessary in treatment. I hope that my short relationship with George did not scare him from ever seeing a psychiatrist again. In some ways, I suspect that by simply listening to George and withholding forced treatment, he will be more inclined to seek treatment in the future.”

I found that last sentence in the first paragraph rather indicative of why I suspect the patient probably had more Axis 2 factors than considered, worry less about him than many of other patients.

Often clinicians, more so subconsciously, do in fact realize the empathy and concern for patients in our care is there for people with illness we can have some impact, and the patients inherently are more cooperative and accepting of our efforts.  Most Axis 2 patients do not have those interests and abilities to work with providers, and thus why I sense Dr Badre, as I interpret, betrays his real feelings and conclusions, although with his vignette George does seem to have some success with progressing with Dr Badre’s help.

Anyway, to wrap up this post, I wonder why psychiatry doesn’t have more discussions like this in various periodicals?  Maybe because we are too busy selling meds for every ill and discomfort, because that is all we are good for these days, for the most part.

But, at least I was fortunate to have these reads this week.  And now readers can have them as well, and wonder what is best for the people.

fork-in-the-road

Ironic I found this picture from a prior post, my feelings exactly with coming up on 5 years with this blog, and yet again wonder if I should continue or not…

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