The lines of palliative and psychiatric services may increasingly intersect as demand for collaborative care swells among seriously ill populations with mental health conditions.
Though palliative care and behavioral health collaborations can be beneficial for patients, widespread misconceptions and a fragmented health care system represent significant headwinds curbing growth.
The impact of limited access to palliative psychiatry can include poor quality outcomes for those with mental health conditions, according to Dr. Priya Krishnasamy, associate professor in the departments of geriatrics, palliative medicine and psychiatry at the Icahn School of Medicine at Mount Sinai Health System. Seriously ill seniors with severe mental illnesses (SMIs) are at particular risk of adverse health effects, Krishnasamy indicated.
“The most challenging cases are patients with severe mental illness and severe medical illness,” Krishnasamy told Palliative Care News. “There’s just extra layers of what we all need to be aware of with this patient population. Patients with these illnesses suffer in regards to quality of life and how outcomes – both mental health but also physical outcomes, can be worse.”
Understanding palliative psychiatry
Misconceptions about their services are among the challenges for both palliative care and psychiatry providers.
On the palliative side, these services can often be conflated with hospice for patients reaching the end of life versus serious illness care that can be accessed further upstream.
On the psychiatric care side, biases, stigma and stereotypes around SMI conditions represent a large barrier to access, according to Krishnasamy. Patients with SMIs often have a greater likelihood of mistrust for the health care system as a result of encountering these misunderstandings, she indicated.
The most challenging cases are patients with severe mental illness and severe medical illness. There’s just extra layers of what we all need to be aware of with this patient population.
— Dr. Priya Krishnasamy, associate professor at the Icahn School of Medicine at Mount Sinai Health System
Despite the hurdles, palliative psychiatry care models are gaining ground in pockets across the globe. Roughly 98% of 206 psychiatrists in India indicated that palliative psychiatry was an important part of reducing suffering among seriously ill patients with SMIs in a recent study.
Additionally, a palliative psychiatry approach in Canada has offered a new path of care for chronic and terminally ill people with SMIs. The nation may be on the precipice of passing a law that would enable patients with mental illness assistance in accessing palliative and hospice care when appropriate in their disease trajectories, according to a recent report.
Palliative psychiatry is a vastly underutilized care model in part due to the common misunderstandings on both sides of the coin, according to the report’s author Dr. Anand Kumar, professor and head of the department of psychiatry at the University of Illinois in Chicago. Kumar previously served as president of the American Association for Geriatric Psychiatry and director of the University of Illinois’ Center on Depression and Resilience.
“Palliative psychiatry isn’t an approach, necessarily,” Kumar told Palliative Care News. “The term is underused and not used at all. The conceptual framework of palliation and palliative psychiatry are not there. It wouldn’t necessarily be a new approach. It should be integrating that framework. How do we deal with patients who don’t respond to medication? That is a more fundamental issue that people in the field have to deal with.”
Palliative care and psychiatry also share some common ground in terms of services and approaches, according to research from BioMed Central. Both services have “evolved historically” past medical interventions, and both are “grounded in the biopsychosocial model” that typically operates with an interdisciplinary approach, the research found.
Patients with mental health conditions are most frequently referred to palliative services when they have exhausted all other medical treatment options, said Author Health CEO Dr. Katherin Hobbs. Hobbs is also a psychiatrist. Author Health serves patients and families in Florida and Texas and has a person-centered, team-based behavioral health care approach.
These patients could benefit from palliative services such as goals of care conversations and advance care planning much sooner in their illness trajectories, according to Hobbs.
“My first questions would be have they exhausted all options, and is this desire for palliative psychiatry coming from a place of the mental health condition itself,” Hobbs said. “Those would be two of my major concerns that I would want to make sure are clear. For the provider, it’s getting very clear with the patient and their caregiver on what their goals are and let’s build a plan around those goals. It really is about the needs of the patient and the desires of the patient and their family, that our system needs to be built around. If we were able to do that, then we could embrace this concept.”
Increased awareness of and access to palliative psychiatry will take stronger communication across the care continuum, Hobbs added.
“Number one is having a really strong relationship with treatment providers who are open to allowing the patient and their caregivers to lead care,” Hobbs said. “That is a central tenet of behavioral health care but that is practiced with variation. [It’s] also us developing a behavioral health system that is flexible in that way that can allow people to still be engaged in the system even if they’re following treatment on a course of how they want to manage their care. Our system has difficulty being flexible in that way.”
Greater collaboration between palliative care and behavioral health providers could go a long way in providing more goal-concordant care to seriously ill patients with SMI, Krishnasamy said. Providers have room for improvement when it comes to recognizing and addressing the “incredible symptom burden” and complex decision making among these patients, she stated.
SMI patients with serious physical illnesses often have less access to appropriate medical care and mental health services, according to Krishnasamy. These patients also have more difficult and complicated health trajectories, she added.
“It’s just so fragmented for these patients and it’s hard to have good transitions from inpatient and outpatient [settings],” Krishnasamy said. “Hopefully there’ll be more behavioral health homes that house psychiatry expertise, palliative and primary care and have access to other specialists as well [to have] more of this interdisciplinary team input. An ideal model would be to meet patients where they are in the home.”
Challenges in palliative psychiatry
An estimated 20% of seniors 55 and older experience some type of mental health concern, the U.S. Centers for Disease Control and Prevention (CDC) reported. Anxiety, depression, cognitive impairment and mood disorders are the most commonly reported conditions among this age group, the report found.
Individuals with an SMI represent a small, but significant population with oftentimes difficult health trajectories to traverse. Nearly 5% of adults 65 and older will have an SMI in the next decade, according to a report from the Substance Abuse and Mental Health Services Administration (SAMHSA).
Addressing palliative needs among SMI populations can be a difficult feat for providers, according to Dr. Vance Brown, chief medical officer of Androscoggin Home Healthcare + Hospice. The nonprofit organization offers home health, hospice, palliative care and behavioral health services.
Care models that integrate palliative psychiatry services could move the needle toward improvement, Brown indicated.
“There’s a huge set of overlaying things that dramatically change the trajectory of the illnesses overall that also make it infinitely more challenging to care for folks who have some of those sensitive issues,” Brown told Palliative Care News. “They’re more difficult to connect with. [There’s] a strong need for folks with behavioral health expertise, but [also] from a clinical perspective we desperately need folks who sit right at that interface. We have so many folks who have serious and persistent mental illnesses with far shorter lifespans [and] usually disproportionate burdens of chronic illness, which leads to palliative and hospice trajectories and challenges associated with their care through this whole trajectory.”
We have so many folks who have serious and persistent mental illnesses with far shorter lifespans [and] usually disproportionate burdens of chronic illness, which leads to palliative and hospice trajectories and challenges associated with their care through this whole trajectory.
—Dr. Vance Brown, chief medical officer of Androscoggin Home Healthcare + Hospice
People with SMIs face greater risks of comorbidities than other patients as they age, according to a recent study published in the Journal of the American Medical Association (JAMA) Psychiatry. Those with common SMIs such as bipolar disorder, schizophrenia and severe depression have nearly twice the risk of developing cardiovascular diseases, metabolic syndromes and chronic kidney disease compared to others.
Seriously physically ill populations with SMIs often receive fragmented health care due to a variety of reasons. Case in point, patients with SMIs received palliative care services at an average rate of 0.5%, lower than 1.72% among general populations, the JAMA Psychiatry study found.
A main challenge to improving reach and quality among these seriously ill SMI populations is that their mental health conditions are often under-reported, resulting in patients and families with a wide range of unmet physical, emotional and psychosocial needs, Brown said.
“[It’s] hugely challenging to make sure we’re doing the right thing for patients, and we [can] struggle with some of the ethical issues about patients who may have untreated or undertreated [conditions] in trying to figure out what their goals are,” Brown said.
Behavioral Health Business Reporter Morgan Gonzales contributed to this article.
