Abstract
Concise, readable, and relevant, this new volume succeeds in its goal to summarize the most pragmatic aspects of palliative care psychiatry for specialists in palliative care and mental health alike. Written by three psychiatrists who practice in palliative care settings and have published extensively on these topics, it summarizes current and evidence-based approaches to caring for patients with advanced medical illness suffering from symptoms of cognitive, neurological, psychological, and social distress.
The authors explain in their introduction that the book is aimed to bridge a gap between two disparate groups of clinicians who are their intended audiences:
“on one side, the front-line palliative care providers who lack formal mental health training yet are eager to improve their ability to address psychiatric symptoms, and on the other side, mental health specialists who lack familiarity with palliative care yet are eager to improve their effectiveness in participating with palliative care clinicians in the care of seriously ill and dying patients” (xix–xx).
Given that the needs of these two audiences do not perfectly align, there is necessarily material in the book that is novel to one group and redundant to the other. I am in the latter of the authors' categories, a psychiatrist consulting in the general hospital who frequently works alongside palliative care teams caring for patients with severe medical illnesses. Although I found Chapter 1, entitled Palliative Care 101, to be a helpful overview of the field, I suspect that palliative care specialists could skip it. Conversely, summaries of DSM-5 diagnostic criteria and basic psychopharmacology are more relevant to nonpsychiatrists. Although these redundancies can lead to text skimming at some points, they do serve an important rhetorical purpose; they demonstrate that specialists in these two groups have a great deal to teach one another.
The authors are not shy about their objective to promote the integration of mental health practitioners into palliative care. Chapter 2 introduces the field of palliative care psychiatry and, after briefly summarizing some of the resistances to integration, focuses on delineating how mental health specialists can make themselves relevant in palliative care settings. Against the tides of professional, practice, and systems-level factors, the authors work to convince both sides of the importance of closer collaboration for the sake of patients and families.
The bulk of the chapters, which focus on clinical applications, are more effectively integrated. Six chapters cover common conditions: depression, anxiety, delirium, dementia, insomnia, and substance use disorders. Each chapter is subdivided into sections on epidemiology, assessment, and management and concludes with a table of key points, references, and additional resources. The authors use tables particularly well, introducing broad concepts in their eminently readable text and leaving the specifics for tables clearly named and listed in the table of contents for ease of future reference. Assessment sections include relevant screening tools as well as nuanced differential diagnoses. Evidence-based medicine is cited as much as is feasible, with the caveat that much of the field involves off-label use or interventions that have not been rigorously studied, a point that the authors frequently discuss and contextualize. Although the management sections tend to discuss pharmacological approaches most extensively, they also incorporate psychotherapies, family work, and goals of care discussions. Tables of medications include indications, dosing parameters, and side effect profiles.
Two additional chapters explore areas of intervention in greater depth. A chapter on psychotherapy discusses the role of supportive therapy in palliative care settings and delineates three specific psychotherapies tailored to palliative care settings, meaning-centered psychotherapy, dignity therapy, and managing cancer and living meaningfully. A chapter on pain management and psychopharmacology discusses the use of psychotropic medications for pain management. A final chapter focuses on unique aspects of palliative care psychiatry in pediatric and adolescent populations, including communicating in a developmentally appropriate manner and medication dose adjustments.
In contrast to Chochinov and Breitbart's more comprehensive Handbook of Psychiatry in Palliative Medicine, to which the authors frequently refer, this volume is devised to be succinct. Thus, several topics are beyond the scope of this book. The authors specifically mention not having space to address managing patients with personality disorders, supporting caregivers, and considering ethical issues. Another unexplored but important area of collaboration is caring for patients with premorbid bipolar or psychotic disorders.
Integrating two groups of clinicians with overlapping skills but disparate acculturation and practice patterns is challenging. The authors are effective in addressing their two audiences, reminding us of our common goal of patient care and using knowledge as a unifying force. While empowering palliative care specialists to feel more comfortable utilizing psychotropic medications, they also demonstrate the areas of nuance that may prompt psychiatric consultation. Similarly, they equip psychiatric consultants to consider the relevant factors in responding to the needs of palliative care teams and their patients, and be attuned to areas in which the expertise of palliative care specialists is particularly relevant. In summary, this volume is a valuable resource for clinicians at a variety of levels operating at the intersection of palliative care and mental health, both as a readable introduction and as a convenient reference for clinical practice.