Palliative Medicine and Psychiatry: A Natural Alliance

by Harold Goforth, MD

Palliative medicine is the medical subspecialty that specializes in quality of life and symptom management for those with serious and life-limiting disease. It can be reached through multiple and diverse primary specialty boards, including internal medicine, family medicine, surgery and psychiatry, among others.

Psychiatry is the branch of medicine that specializes in the management of mental illness and general medical diagnoses with psychiatric or behavioral manifestations.

While on the surface the two specialties may seem worlds apart, they actually share a great deal of subject matter. For instance, psychiatry has long maintained a subspecialty in geriatrics that focuses on diseases of the aged. Many of those geriatric conditions are primary diagnoses that palliative medicine also addresses (e.g., dementias) or are consequences of aging and the end of life (bereavement).

This article seeks to demonstrate the overlap of the two specialties and how psychiatry intersects with and contributes to the interdisciplinary nature of palliative medicine. Certainly, both fields value a multidisciplinary approach, with excellent communication skills necessary to the trade.

Shared Appreciation of the Interdisciplinary Team’s Value

One of the determining characteristics of palliative medicine is attention to an interdisciplinary team to evaluate, diagnose and treat the individual. Palliative medicine relies on a biopsychosocial assessment, as does psychiatry, and utilizes supportive medical fields such as nursing, social work, art therapy, chaplaincy, physical therapy and nutrition. It seeks a holistic appreciation of the individual patient, to better help one attain his or her particular goals. The palliative medicine physician is the leader of this interdisciplinary team and coordinates the overall multidisciplinary assessment.

While participation in an interdisciplinary team may be a novel experience for some in medicine, psychiatrists are taught these management and collaborative skills from early in their residency in the assessment of psychiatric illness. Similarly, adopting a biopsychosocial model has long been the standard of care for psychiatric assessment and treatment. Thus, from an overall treatment approach, there is much overlap in the holistic orientation that both palliative medicine and psychiatry use to characterize and better understand their patients.

There is considerable overlap with the two specialties at a more granular level as well. Diagnostically, psychiatrists have long been at the forefront of treating patients with serious and life-limiting illnesses such as dementia and other neurodegenerative disorders ‒ treating them from a cognitive standpoint as well as for the behavioral complications that accompany these diagnoses. In advanced stages of the dementing disorders and associated diagnoses such as Huntington disease, it is common for psychiatrists to treat patients until the time of death. In fact, almost every life-limiting neurological and psychiatric diagnosis comes with profound behavioral alterations; psychiatry routinely assesses and participates in the treatment plan formulation for those conditions.

Linkage in Treating Symptoms

From a symptom-management perspective, much of palliative medicine involves time spent treating pain, delirium, bereavement/depression/anxiety and nausea/vomiting. Each of these areas is the domain of psychiatry as well.

From a pain perspective, psychiatry has traditionally been one of the five avenues to subspecialty pain board certification (the other four being neurology, anesthesia, neurosurgery, and physical medicine and rehabilitation).

Psychiatrists are well-versed through their training to understand both opioid and nonopioid pharmacology ‒ perhaps to a greater degree than any other primary specialty. Not only does psychiatry appreciate the pain relief component of the opioids, but the specialty also is adept at the detection and diagnosis of disease that is typically nonopioid responsive ‒ nonmalignant pain as well as pain exacerbated by existential and behavioral factors. Adjunctive agents such as gabapentinoids and tricyclic antidepressants are utilized in psychiatry for a myriad of disorders, so there is a high degree of comfort with these agents too.

Additionally, psychiatrists have expertise in addictions and medication misuse. While traditionally there has not been a great deal of emphasis on medication misuse in the end-of-life population, as palliative medicine expands to assess and treat patients earlier in the course of their illness, this skill will become more important for the proper management of these patients.

With respect to the complications of bereavement, depression, anxiety and delirium, psychiatry is well-suited for the assessment and management of these disorders. Psychiatrists have a comprehensive understanding of the distinctions of these diagnoses and the differential diagnosis of patients with complex medical issues. From a medication management perspective as well as a psychotherapy standpoint, the psychiatrist finds fertile ground in this subject matter.

At first blush, few would expect psychiatry to be adept at nausea management. However, one must only remember the underlying pharmacology of antiemetics to realize that psychiatry comes to this topic with an in-depth understanding of the medications. Antiemetics work primarily at the site of the dopamine receptors in the brain, along the fourth ventricle, and most antiemetics are dopamine blockers, either directly or indirectly.

Psychiatrists have a long history of using dopamine blockade therapeutically to treat psychotic illness, and they have a deep appreciation of the uses of these medications, including their associated adverse effects. Some of these agents are being used off-label to treat refractory nausea/vomiting with great success (e.g., olanzapine). During a palliative medicine fellowship, physicians will improve their differential diagnosis and management of nausea and vomiting, and learn other appropriate interventions that may include gastric stenting or venting gastrostomy procedures; however, the majority of cases of nausea and vomiting are managed medically by agents familiar to psychiatric practitioners.

Mutually Beneficial Specialties

In sum, there is significant overlap between the holistic orientations of psychiatry and palliative medicine, as well as diagnoses treated and symptoms addressed by both medical specialties. The basis of palliative medicine with family medicine and internal medicine can give psychiatrists a renewed and deepened understanding of the complete physical examination, as well as an enriched differential approach to the diagnosis of disease.

Likewise, psychiatry can lend to palliative medicine an in-depth and more thorough understanding of pain, improved behavioral differential diagnoses, and an increased understanding of addictions and medication misuse.

Dr. Goforth is a staff member of Cleveland Clinic Neurological Institute’s Department of Psychiatry and Psychology, and of the Taussig Cancer Institute’s Department of Hematology and Medical Oncology.