Palliative models of care for later stages of mental disorder: maximizing recovery,maintaining hope,and building morale

Abstract

Background: The concept of staging of disease in psychiatry has developed over the past years. A neglected component of this model pertains to people in the advanced stages of a mental illness, who remain symptomatic and functionally impaired despite treatment. These patients are often high service utilizers, receiving complex multimodal treatments where the balance of risk and benefit shifts perceptibly. In this paper, we argue the need to adopt ‘palliative’ models of care for some individuals, and consider changing the therapeutic goals to follow care pathways similar to those used in other chronic and refractory medical illnesses.

Method: Data was sourced by a literature search using Medline and a hand search of scientific journals. Relevant articles were selected.

Results: Clinical staging can help us better define subgroups of patients who will benefit from different goals and treatment. In the most advanced stage group, we find patients with persistent symptoms and treatment resistance. In these situations, it may be preferable to follow some of the principles of palliative care, which include the setting of attainable goals, reduction of side-effects, limited symptom control, targeting identified psychological and social problems, and attempting to attain the best quality of life for these patients and their families.

Conclusions: It is in the interest of those in the advanced phases of a disorder that clinicians acknowledge the limitations of treatment and actively attempt to plan treatment utilizing alternate models. It is essential to be clear that such approaches do not equate to the abandonment of care, but rather to the reconceptualizing of feasible and personalized treatment goals, a rebalancing of the risks and benefits of intervention, the management of illness behaviour, and the approaches that allow the patient to live gainfully within their limitations.

Keywords

Clinical depression management palliative psychotherapy recurrence staging treatment

Introduction

The presence of a deteriorating illness course in psychiatry has been understood since the early accounts of dementia praecox and course descriptions by Kraepelin (1919). Since this time, a growing body of literature has supported the notion that many psychiatric illnesses demonstrate a staged or continuum model of illness progression. This continuum extends from those individuals with early illness remission to those who manifest a progressively deteriorating course into severe persistent psychiatric symptomatology. Data from large-scale naturalistic clinical studies in depression (Star*D; Gaynes et al., 2009; Rush et al., 2009) and schizophrenia (CATIE; Lieberman, 2007; Swartz et al., 2008) consistently demonstrate that although many individuals stabilize and recover, a substantial minority do not respond despite optimal treatment. Star*D in particular paints a picture of a serially declining probability of response with each new treatment attempt. Despite this, almost no guidelines address the needs of people who fail to respond to treatment, beyond suggesting novel and experimental therapies that have a poor probability of utility in a refractory population (e.g. Yatham et al., 2005). In conjunction with this, the risk−benefit ratio of treatment shifts appreciably, with a declining probability of response paired with increased risks of adverse events with novel or complex therapies.

Staging

In most illnesses, prognosis becomes poorer as disease progresses. In medical specialties like oncology and cardiology, clinical staging is a routine tool utilized to inform treatment decisions and provide insight into prognosis. For example, the management of early stage cancer, where prognosis and treatment response is better, incorporates an active and curative approach. As disease progresses to advanced stages, the goals of treatment are radically different. The palliative model of care in these disorders was developed around these needs.

The concept of staging in psychiatry has recently been advanced, with McGorry and colleagues leading efforts to stage the treatment of psychiatric disorders (McGorry, 2007; McGorry et al., 2006, 2007, 2010). Such clinical staging of psychiatric illnesses spans and cuts across our traditional diagnostic categories, which represent the mid- or late stages of disorders that have emerged from less overtly phenotypically divergent earlier clinical stages well after the onset of initial symptoms. There is a temporal progression from the earliest stages of illness, with remission or progression possible at each stage. In the earliest asymptomatic stage, one finds people at risk of developing the illness (including those with a family history, intercurrent stressors, and substance abuse) but who have not yet developed clinical symptoms. Some of these individuals will express this risk, while others will remain well. The next stage involves clinical symptoms with impairment and need for care, yet without the syndrome clarity to distinguish between discrete clinical phenotypes. Of these individuals, a proportion will progress to the next level or stage of disorder with a first episode (Yung et al., 2008). Some individuals continue progression to even later stages, involving recurrences or chronic illness. It is around the first episode that some of the traditional syndromes such as mania, psychosis, and severe depression begin to make sense. In the most advanced stages, we find patients with persistent and unremitting illness despite having received several treatments (Table 1). A decreasing likelihood of response as people progress through the stages is now clearly documented (Berk et al., 2011b).

Table 1.

A potential clinical staging model for bipolar disorder (adapted from McGorry et al., 2006, 2007 with permission)

Clinical stage	Definition	Potential interventions
0	Increased risk of severe mood disorder (e.g. family history, abuse, substance use), but currently asymptomatic	Mental health literacy, self help
1a	Mild or non-specific symptoms of mood disorder	Formal mental health literacy Psychoeducation Substance abuse reduction Cognitive behavioural therapy
1b	Prodromal features (ultra-high risk)	As for 1a plus therapy for episode: phase-specific or mood stabilizer
2	First episode of full-threshold mood disorder	As for 1b plus case management and vocational rehabilitation
3a	Recurrence of subthreshold mood symptoms	As for 2 plus emphasis on maintenance medications and psychosocial strategies for full remission
3b	First full-threshold relapse	As for 3a plus relapse prevention strategies
3c	Multiple relapses	As for 3b plus combination mood stabilizers
4	Persistent unremitting illness	As for 3c plus clozapine and other tertiary therapies Social participation despite disability

A number of caveats regarding staging are nevertheless warranted. While this model was developed to be broadly applicable across diagnoses, not all disorders follow this clear trajectory; borderline personality for example improves with the passage of time. The model is weighted around the earliest stages of the disorder, in order to maximize the potential to intervene as early as feasible, and most patients seen clinically will be in the latter stages. The staging model has been adapted to specific disorders such as eating disorders and bipolar disorder (Berk et al., 2007; Maguire et al., 2008), which have unique characteristics. While some individuals have a persistently benign and responsive course over time, for others, their illness takes an aggressive course from the outset and rapidly manifests treatment resistance without passing through the described clinical stages. Lastly, there is an overlap between staging models and models of treatment resistance (Ruhe et al., 2011).

People in the early stages of illness tend to have a better prognosis and a more favourable treatment with established psychological and biological treatments (Vieta et al., 2009). They also generally require simpler and less invasive treatments, and may benefit from efforts to minimize the additional secondary burden of their disorder including stress, disruption of developmental stages, and occupational and social dysfunction.

Ideally, disease stages should be defined in terms of biomarkers or neuropathology, as is the case in physical medicine. However, while there has been substantial progress towards this aim, sensitivity and specificity issues make this a future goal rather than a current reality and our classifications remain based on clinical symptoms. Both genetic (Archer et al., 2010) and endophenotypic staging markers, including changes in brain anatomy (Pantelis et al., 2009), neurotrophic, and pro-apoptotic factors (Kapczinski et al., 2009) and other endophenotypes, have been found, and some studies have found neurobiological correlates between different stages of the same psychiatric illness. However, the use of such correlates is hampered by their relatively low sensitivity and poor specificity.

‘Allostatic load’ is defined as the physiological costs of chronic exposure to the physiological responses resulting from repeated or chronic stress. Chronic stress, multiple relapses, and/or drug abuse may combine to produce a high allostatic load, resulting in progressive biological changes. These may in turn be associated with higher rates of psychiatric symptoms, relapses, and cognitive decline. Similarly, comorbid medical diseases like hypertension, diabetes, cardiovascular disease, and cancer can contribute to the cumulative burden of the more advanced stages of psychiatric illness (McEwen, 2000). One possible implication of this theory is that effective early psychological and/or pharmacological treatment may help prevent the cascade of adverse neurobiological changes, thus preventing disease progression and improving global prognosis (Berk et al., 2010b; Yung et al., 2007). In contrast, structural and functional brain sequelae evident in the later stages of illness may actually reduce the effectiveness of established interventions, developing a state of treatment resistance. This overlaps with the concept of neuroprogression, which suggests that there is an active pathophysiological process underpinning the staged trajectory (Berk, 2009).

Psychological changes associated with illness progression may reduce the effectiveness of commonly employed psychotherapeutic interventions. For example, cognitive behavioural therapy (CBT) techniques are founded around the ability to observe one’s behaviour, challenge irrational thoughts, and develop strategies for addressing and managing distressing thoughts and feelings. The required level of executive functioning and motivation to complete tasks outside of sessions and the attentional demands of CBT may exceed the capacity of more chronic and treatment-resistant patients who suffer from illness-related cognitive decline (Berk and Parker, 2009). Research into the use of CBT for patients with treatment-resistant schizophrenia has produced mixed findings. A Scandinavian study of 72 patients with schizophrenia with antipsychotic-resistant symptoms did not demonstrate a sustained effect of CBT after discharge from hospital (Valmaggia et al., 2005). In contrast, one CBT-based trial in patients with treatment-resistant schizophrenia did demonstrate improvement in overall symptomatology and negative symptoms, but not levels of depression (Sensky et al., 2000). Studies of psychological treatment outcomes for treatment-resistant depression have also produced inconsistent results. The recent findings of the 2009 REVAMP study indicated no significant improvement with a form of cognitive behavioural and supportive psychotherapy as compared to placebo (Kocsis et al., 2009), whereas another large-scale study found that chronic treatment-resistant depression benefited from a combined pharmacological and psychotherapeutic approach (Keller et al., 2000). Overall, when assessing the neuropsychological deficits and structural changes observed in chronic psychiatric illnesses and considering the motivational, self-esteem, learned helplessness, and schema-based factors that can precipitate, potentiate, or worsen the illness, it is clear that more complex therapies may not meet the needs of chronic and treatment-resistant individuals.

Preliminary evidence suggests that psychotherapy can be associated with clinical deterioration in chronic and refractory psychiatric illness (Scott et al., 2006). Poorer treatment responses occur during advanced stages of illness and in patients with more severe disability and cognitive impairment (Berk et al., 2010c). This pattern is also suggested in studies of psychoeducation, which may reduce relapses in patients with bipolar disorder (Reinares et al., 2010) and improve psychopathology and disability in those with schizophrenia (Xia et al., 2010), but may be less likely to benefit patients in the advanced stages of illness (Kopelowicz and Liberman, 2003).

The care of patients with chronic mental illness is often an unpopular area of engagement for mental health workers (Minkoff, 1987). Chronicity and treatment resistance can lead clinicians to feel helpless and burnt out, facilitating high rates of staff turnover and a desire to ‘throw everything’ at treatment-resistant patients hoping for a response. Individuals with advanced and refractory illness frequently receive complex treatments where the balance of risks and benefits shifts perceptibly. Experimental, off label, high-dose, or combination regimens may risk more side effects and interactions, while simultaneously having a lower chance of achieving a response. Those who exhibit continuing treatment resistance often progress to poorly tolerated, less evidenced-based, and experimental treatments. Clinicians frequently commence treatments with more enthusiasm than they stop them, running the risks of continuation of ineffective therapy. Polypharmacy with antipsychotics, for example, may result in higher rates of metabolic syndrome and insulin resistance (Correll et al., 2007).

Side effects are not the only risk. Continued aggressive, yet ineffective, treatment may influence dependence on the healthcare system and engender inappropriate expectations. Trivedi et al. (2006) demonstrated that the likelihood of treatment response in depression diminishes sequentially with each new treatment trial. In patients with established treatment resistance, the likelihood of response to a subsequent treatment attempt becomes minimal (Trivedi et al., 2006). With each failed trial of treatment, providers, patients, or family members may feel a sense of failure and despair. As learned helplessness is one of the most powerful psychological predictors of depression (i.e. the hopeless and helpless individual), this constant cycle of failure and inability to escape risks worsening the illness. While many patients will be disheartened by a series of unsuccessful treatments, it is critical that they are not given a sense that their doctor has ‘given up’. The balance needs to be struck between being realistic about what can be achieved, continuing actively to find the best treatment, while reformulating goals that are attainable.

An important caveat pertains to the quality of prior care. There is a risk that some clinicians may be unassertive with chronically ill or difficult to treat individuals, risking substandard therapy that does not include all viable treatment options. It is necessary to emphasize that this model should only be applicable to those who have truly exhausted appropriate algorithm- or guideline-based care.

Another factor that should be considered is waste of healthcare resources. Patients who are continued on ineffective and potentially harmful pharmacological or psychological therapies are subject to ‘medical waste’ (defined as ‘any intervention that has no possible benefit for the patient or in which the potential risk to the patient is greater than potential benefit’; Fuchs, 2009). Appropriate staging of individuals may lead to more appropriate allocation of finite resources away from ineffective therapeutics toward other areas (e.g. psychosocial supports). The misallocation of finite resources may also reduce access to care for other patients in need.

The symptom-focused models that are embodied by acute care paradigms in routine practice are sometimes not useful, and it might be more appropriate to adopt models of palliative care for some patients with treatment-resistant psychiatric illness. The World Health Organization (1990) defines palliative care as: ‘The active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms and of psychological, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best quality of life for patients and their families’. Palliative care focuses on reducing the severity and impact of disease symptoms, as opposed to attempting to halt, delay, or reverse progression of the primary disorder, and explicitly does not aim to provide a cure. The principal aim is to prevent and relieve suffering and to simultaneously improve the quality of life in individuals with chronic or complex disorders. Palliative care is independent on prognosis and is offered in parallel with other appropriate medical or psychological treatments. In this context, it is an imperfect metaphor, as its association with chronic and refractory illness is contaminated by its origins in cancer medicine, with all the inherent connotations such as lethality, which are overtly inapplicable.

It is essential to stress that the term ‘palliative’ does not equate to lethality, withholding, absence of treatment, or extinguishment of hope. In oncology, utilization of palliative approaches has been shown to improve outcomes more than new and expensive treatments, reduce the futile use of finite resources, and reduce carer burden (Haines, 2011). A palliative treatment in psychiatry may imply the redefinition of objectives, using philosophies that we have learned from the management of other chronic diseases, such as enhancing quality of life, handicap minimization, and redefinition of goals. In contrast to oncology, this approach is quite different from giving a dying cancer patient better quality of life, while the disease progresses unchecked. A strengths-based treatment such as acceptance and commitment therapy (ACT) may succeed in improving quality of life, mood, and behaviour and thus can successfully treat core features of the disorder itself. While such approaches may not reduce core symptoms in disorders with a major neurobiological component, such as schizophrenia, the reduction in rehospitalization and improvement of quality of life remain core benefits. This management philosophy has many similarities to the strengths model (Chopra et al., 2009) and also overlaps to a significant degree with the goals of the consumer-driven recovery movement (Tilsen and Nylund, 2008).

Strauss has used the term ‘woodshedding’ to refer to the attainment of a plateau following illness; this type of regulatory mechanism provides a protected opportunity for the person to deal with the psychological challenges involved in re-establishing one’s place in life after a period of illness (Strauss, 1989). Attention to these mechanisms, along with a patient’s subjective experience of their illness and response to this, deserve a greater place in the care of those with chronic illness.

Illness beliefs and illness behaviour

One consequence of the medicalization of chronic disorders encompassing repeated trials of treatment is an increased risk of abnormal illness behaviour. Clinicians should be aware that providing unrealistic expectations to patients with chronic and refractory illness might aggravate the risk of the adoption of the sick role and abnormal illness behaviour. Appropriately aligning a patient’s expectations of treatment and recovery can facilitate the appreciation of small and attainable goals, while reducing discomfort and improving quality of life.

Mechanic (1962) defined illness behaviour as the way that symptoms are perceived, evaluated, and acted upon by the patient (McHugh and Vallis, 1986). The presence of a chronic illness requires the individual to adopt coping and adaptive strategies to integrate the resulting impact and limitations on their life (Moos, 1982). Some illness behaviours are clearly less appropriate or adaptive to an individual’s circumstances than others (Pilowsky and Spence, 1975). Differing beliefs about their illness may influence why some individuals take longer to recover or fail to fully recover (Leventhal et al., 1992). In the sick role, an individual is exempt from certain normal obligations and life tasks but also has several obligations, the latter including a tacit acceptance that being sick is undesirable and a return to health is desired. Some individuals struggle to adjust out of the sick role and may become stuck in the quagmire of illness. Illness investment can be a feature of some individuals with chronic disorders, where illness might increasingly define their identity and provide a cognitive schema for the demands, complexities, and failures in their lives (Berk et al., 2010b). Alternatively, coming to terms with disability may involve a grief process culminating in a new focus on actively engaging in life. This greater level of insight and self-reflection allows individuals to realistically incorporate the requirements of management of their disorder and the limitations it imposes into appropriate and meaningful life goals.

Illness behaviour is related to illness perception and belief. The patient’s perception of the cause, consequence, and identity of the illness, as well as its expected duration can be implicated in enhancing or obstructing health behaviour (Haller et al., 2008). This is a neglected component of the latter stages of illness and is one area where a strategic intervention may be fruitful. Certain illness beliefs can make people reluctant to seek treatment and/or harm treatment adherence (Berk et al., 2004, 2010a). These beliefs may be modulated by stigma, which could impact on social reintegration. It may be useful to detect and measure behaviours, cognitions, and beliefs around illness and illness investment (Berk et al., 2010b) and to establish a quality therapeutic alliance with clear and attainable objectives. The therapeutic alliance should include family members who often play a primary care-giving role and may not have information about the disease and of the desired goals. Primary caregivers of patients with more disability and episode frequency experience greater carer burden, depressive symptoms, and other health problems (Berk et al., 2011a).

This may undermine their capacity to provide appropriate care. Extensive use of social support systems should be applied. Social interventions with skill training and medical case management may improve psychosocial functioning in patients with chronic or severe mental illness (Mueser et al., 2010). To improve the quality of life for caregivers, it is vital to promote broad social and psychosocial support (Perlick et al., 2010).

Therapeutic implications

Some established therapeutic models could be of particular value in conceptualizing appropriate models of care for this clinical scenario. ACT consists of acceptance of those components of life that are within one’s control and committing to whatever course of action can improve or enrich life (Hofmann et al., 2010). It specifically does not target symptoms as pathological entities and aims to increase autonomy and control within the limitations of a person’s life situation, resources, and abilities. It teaches people to be psychologically present: to consciously connect with whatever is happening right here, right now, step back or detach from unhelpful thoughts, worries, and memories, and open up and make room for painful feelings and sensations. People are taught to drop the struggle with painful feelings and sensations and to create a distance between themselves and these experiences by increasing awareness of whatever they are thinking, feeling, or doing at any moment. Lastly, it includes doing what matters to their life goals and plans, even if it is difficult or uncomfortable (Arch and Craske, 2008). A critical component of the latter is a focus on overt behaviours that produce valued outcomes. It increases tolerance of distress, even if distress is not reduced. This framework is largely compatible with, and may provide a template for, the optimization of a therapeutic model aimed at meeting the needs of individuals in the latter stages of illness. ACT has been used to manage chronically psychotic individuals, where it has been to be associated with lower rehospitalization rates (Bach and Hayes, 2002).

Patient insight and cognitive capacity will influence a ‘palliative’ treatment paradigm in psychiatry. It is necessary to individualize treatment for all patients and all stages. The choices and goals of treatment will differ for patients with limited insight (e.g. patients with chronic schizophrenia living in extended supported care) from patients with a chronic treatment-refractory mood disorder complicated by drug abuse. In patients with chronic treatment-resistant schizophrenia, goals directed at reducing anxiety and maintaining stability may provide more useful that psychosis reduction. In essence, treatment goals need to be individualized and tailored to a variety of clinical variables, including motivation, engagement, personality, comorbidity, insight, social supports, disability support, cognitive factors, and prior history.

Targeting comorbidities

A consequence of persistent distress is the temptation to self-medicate with alcohol and other recreational drugs. Drug misuse is therefore one of the most common comorbidities in chronic and treatment-resistant patients. Drug misuse can impede the effectiveness of treatment as well as worsen the overall health of the patient. In mood and psychotic disorders, alcohol abuse and dependence is associated with poorer functioning and higher rates of suicide attempts (Cardoso et al., 2008; Oquendo et al., 2010). Even smoking appears associated with poorer outcomes, particularly in mood disorders (Berk et al., 2008; Pasco et al., 2008; Ashton et al., 2010; Dodd et al., 2010; Mathews et al., 2010). It is therefore important that secondary causes of disability and treatment resistance such as substance abuse are actively managed.

Conclusions

The management of individuals with refractory difficulties is a common clinical dilemma, and there is little guidance regarding management. This group of individuals is additionally over-represented in systems of care, as these service systems of care act as filters that attract symptomatic individuals in distress and discharge responders.

It should be noted that the term ‘palliative treatment’ in psychiatry could have negative connotations and, while providing a template for management of individuals with chronic and refractory disorders, it needs to used with caution, if at all, lest a message of hopelessness is interpreted. In the age of the internet, while professional thinking cannot be withheld from the wider community, the manner and formulation in which information is communicated needs to be sensitive and concordant with an understanding of the person’s needs, mental status, and level of acceptance. The term ‘palliative’ itself many need to be reformulated in the roll-out of treatment programmes (Baksheev et al., 2010; Xiang et al., 2010). Palliative approaches definitively should not be equated with the abandonment of hope or care but with a reformulation of goals. Setting meaningful and attainable goals may increase hope and reinforce effort, whereas actively chasing a sequence of failed treatments can lead to hopelessness via recurrent failure. Currently we do not have good, clear phenomenological, clinical, or biological markers that allow us to perform an accurate prognostication in clinical practice. Sometimes those who lack adverse prognostic markers can do badly, and chronic and severely unwell individuals can make considerable improvements. As such, this approach needs to be used flexibly and to be reactive to changes in clinical and lifestyle circumstances.

The concept of ‘palliative treatment’ may be useful in guiding the treatment of patients with high disability who frequently receive aggressive or high-risk treatment. Evidence suggests patients in advanced stages of some psychiatric disorders respond more poorly to established treatments (Dassa et al., 2010). Clinicians should carefully assess the benefits and risks involved with management strategies pursued (Kim et al., 2010; Lowe et al., 2010; Stain et al., 2010). Setting attainable goals, reducing side effects, meeting the informational needs and desires of the patients and their families, controlling some symptoms, and establishing social and family supports can often lead to a greater quality of life.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Acknowledgements

The authors would like to thank Jane Morton for her assistance with the manuscript.

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