Palliative medicine and psychiatry: a reply.

JOURNAL OF PALLIATIVE MEDICINE Volume 16, Number 10, 2013 a Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0246 Letters to the Editor Palliative Medicine and Psychiatry: A Reply Thomas Strouse, MD Dear Editor: In the April edition of this journal, Sandy Macleod, a New Zealander who is both a psychiatrist and palliative care physician, outlines why psychiatric skills and knowledge— and, at least ideally, psychiatrists—are important in the landscape of caring for patients, families, and clinicians cop- ing with catastrophic medical illness and death. 1 His argument seems straightforward. Not only are psychi- atrists experts in assessing and treating the ‘‘ordinary’’ psy- chiatric components of advanced medical illness, such as problems with mood, anxiety, coping, and delirium; Macleod also posits that the neuropsychiatry of palliative care patients has become more complicated as a function of treatment ad- vances that extend survival but may also be associated with greater central nervous system toxicity and longer periods of time for patients to experience existential uncertainties. How- ever, Macleod’s praise of psychiatric expertise in palliative care is faint: although the circumstances he outlines might call for more psychiatrists rather than fewer, his view is that they are too scarce in palliative care clinical settings to do much good: ‘‘The relevant knowledge and skills obtained from the disci- pline of psychiatry are not, and will never be, delivered by its expert practitioners in a palliative care unit.’’ And therefore his view is that nonpsychiatrist palliative care docs need to de- velop skills to make up for psychiatrists’ absence. Too fatalistic? Perhaps. Psychiatrists have labored at the interface of medicine and psychiatry for decades, and there is reason to be optimistic that their presence will grow. This work is central to the field of consultation/liaison psychiatry, 2 psycho-oncology, 3 and hospice and palliative medicine. 4 Forty years ago the British psychiatrist Colin Murray Parkes was instrumental in early efforts to demonstrate improved outcomes for hospice enrolled patients and their survivors, as well as the safety and efficacy of the use of opioids, at St. Christopher’s Hospice in London. 5 The American psychia- trist William Lamers founded the Hospice of Marin in North- ern California and was instrumental in introducing palliative care content into medical school curricula. 6 Jimmie Holland’s pioneering work in the field of psycho-oncology now includes a three decades old psycho-oncology fellowship training program that is closely linked with palliative care training at MSKCC; 7 a comprehensive textbook of psycho-oncology now in its second edition; 8 and nationally endorsed evidence- based treatment guidelines for cancer-related distress 9 and has spawned second and third generations of psycho-oncologists who invent new approaches, some of which Macleod men- tions in his editorial. The Institute for Palliative Medicine at San Diego Hospice recently chartered the first palliative care psychiatry fellowship program in the United States. 10 In addition to a history rich with clinical and scholarly col- laboration by psychiatrists with other physicians in the pallia- tive care setting, two new forces may work in favor of greater psychiatrist presence in the future. The first is the growing evidence that supports ‘‘integrated care’’ for the management of psychiatric disorders co-occurring with medical illnesses. 11 Medically ill patients with comorbid psychiatric problems tend to do better both medically and psychiatrically, while con- suming fewer health care dollars, when their mental health care is provided in the medical setting. Health care delivery orga- nizations that are accountable for the care they provide un- derstand this more positive outcome, and are making it a priority to embed sophisticated behavioral health services into primary care—an approach that many progressive cancer care delivery systems have been practicing for years. 12 The second factor is impending health care reform in the United States. Health systems will need to adopt deliberate, quantitative, population-based strategies to care for the millions of newly insured patients who are likely to be seeking services. These strategies will necessarily include building and expanding palliative care and behavioral health/psychiatric consultation services, since both disciplines have repeatedly demonstrated their value in improving care and lowering costs. A related ‘‘leading edge’’ trend is the evolution of the clinical role of the psychiatrist/psycho-oncologist into that of a more fully formed palliative care physician. The interrelat- edness of psychological distress or frank psychiatric disorder with physical aspects of advanced medical illness are opti- mally evaluated and treated by physicians with both interest and expertise in these related areas. Just when primary on- cologic physicians are most inclined to be ‘‘splitting,’’ the psychiatrist/psycho-oncologist-palliative care physician is ‘‘lumping’’— by remaining clinically present, and by defining as broadly as possible the scope of symptoms and problems he or she will attend to as the emphasis moves away from disease-modifying treatments and on to relief of suffering and improving quality of life. Psychiatrists trained in the last 30 years generally possess the ‘‘standard equipment’’ needed to function well as palliative Palliative Care Research and Education, Department of Psychiatry, UCLA David Geffen School of Medicine, Los Angeles, California.