Our Unrealized Imperative: Integrating Mental Health Care into Hospice and Palliative Care

Abstract

The field of Hospice and Palliative Medicine (HPM) has its roots in the principles, promulgated by Dame Cicely Saunders, that patient and family are the unit of care and that comprehensive integration of physical, psychological, social, and spiritual care is necessary to address suffering in all its dimensions. Although we aspire to provide comprehensive care for our patients, most hospice and palliative care (HPM) physicians lack basic competencies for identifying and managing patients with psychological distress and mental health distress and disorders, a growing segment of our clinical population. In this article, I argue that we are not living up to the founding values of our field in how we practice, how we educate our trainees, our research, and in how we pursue our own professional development as faculty. The history of our field, the nature of our clinical workforce, the culture of PC, and our educational programs all contribute to our current practice model, which is not adequate to meet the mental health needs of our patients. I propose strategies to address these challenges focused on enhancing integration between psychiatry/psychology and HPM, changes in fellowship education and faculty development, addressing the stigma against people with mental health diagnoses, and addressing system and cultural challenges that limit our ability to provide the kind of comprehensive, integrative care that our field aspires to.

Introduction

Although we aspire to provide comprehensive care for our patients, most HPM physicians lack basic competencies for identifying and managing patients with mental health distress and disorders, a growing segment of our clinical population. In this article, I argue that we are not living up to the founding values of our field in how we practice, how we educate our trainees, our research, and in how we pursue our own professional development as faculty. Some of these challenges are beyond our control; however, many are not. Gaps in the provision of care for the mental health problems of our patients are underrecognized and underacknowledged in our field, leading to their perpetuation. Serious ramifications ensue, both for our patients and their families and for ourselves as clinicians. Patient/family consequences include missed or misdiagnoses, unmet needs, and non-evidence-based care; for clinicians, these gaps contribute to moral distress and burnout. Our educational programs perpetuate these deficits through little and inadequate teaching by nonexperts about mental health topics for our trainees. Research does not adequately address mental health outcomes.

In approaching this topic, I will focus on physicians primarily, and my emphasis is on palliative care (PC) , although hospice physicians (and other clinicians) share many of the same challenges. We are an interdisciplinary field, but my experience and expertise are as a physician. I see nurses and Advance Practice Nurses (APRNs), physician assistants, social workers, psychologists, psychiatrists, chaplains, and pharmacists as key partners for achieving the goal of integrated care. I recognize that each discipline has its own culture and history and will have unique issues and solutions in moving toward greater integration. I see this outline as a starting point, not an answer. I hope that disciplinary experts in these diverse areas will be moved to pursue these issues both in their own areas and together.

I also acknowledge the need for a broad and deep consideration of how inequities, both in HPM and in mental health care, affect our capacity for patient-centered integration of mental health into HPM. While beyond the scope of this article, this topic deserves intensive focus at all levels, including global improvements in access to mental health care, recruitment of diverse clinicians, sophisticated understanding of the role of inequities in serious illness care, research and development, and promulgation of innovative educational approaches addressing this vital issue.

I approach these observations and reflections from my own experience. I was trained and board certified as an internist and psychiatrist. I have been practicing HPM since 1982, when I was introduced to this work as a hospice medical director and began working to educate internal medicine (IM) residents in the field. This work has been both local, within Harvard Medical School and local hospices, and national. I spent much of the 1990s working on building the field of HPM nationally, developing and implementing national faculty development programs, and teaching and building HPM infrastructure at Harvard Medical School, including the Harvard Medical School Center for Palliative Care. Between 1998 and 2015, as the Founding Department Chair of the Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute and Brigham and Women’s Hospital (now the Department of Supportive Oncology), with the vision of developing an academic, fully-integrated care model that addressed patient and family needs, I built programs in psychooncology, palliative care, and bereavement care, integrated adult and pediatric HPM programs, and led the integration of social work into our department. We developed a robust clinical service, an interdisciplinary fellowship program, educational programs for medical and nursing students, residents, fellows, and faculty, a research program, and led improvements in care for people with serious illness throughout the entire Partners (now MGB) Health System. I envisioned the Department as a vehicle for integration of adult and pediatric mental health services delivered by psychiatrists, psychologists and social workers, and PC teams, including physicians, nurses, APRNs, physician assistants, pharmacists, and social workers.

For the past 20+ years, I have led weekly interdisciplinary seminars for students, residents, fellows, and faculty/staff in the department on psychosocial issues in PC. In these rounds, with our expert, compassionate, earnest interdisciplinary teams, I have been struck by several patterns: (1) the increasing prevalence of mental health disorders among our patients; (2) clinicians’ difficulty with basic mental health assessment, pattern recognition, and diagnosis; (3) challenges in addressing and managing transference and countertransference; and (4) inadequate understanding of grief and bereavement. In addition, I have noted several factors on the clinician/system side: (1) high levels of moral distress and dysphoria over the challenges of understanding and managing psychologically complex patients; (2) difficulty engaging psychiatrists and other mental health clinicians in working in an integrated way with PC; and (3) increased reliance by non-PC and non-psychiatry clinicians on HPM specialists to manage complex patients.

It has been more difficult than I had dreamed to achieve the goal of integration. I believe that the maturation of HPM, the existence of many mature and maturing HPM programs across the country, recent efforts, often under the rubric of Supportive Oncology, as well as developing behavioral health integration models within psychiatry and primary care make this a fruitful time for forward movement to address these challenges to better integrate mental health expertise and care into the care of people with serious illness.

My optimism is somewhat countered by my concerns about developments in the field of Psychiatry, which, while benefitting from growing understanding of neurobiology and psychopharmacology, has deemphasized the teaching and practice of psychodynamics and psychotherapy, which are integral to the care of patients living with serious illness. Attention to the role of stress, social factors, development, the role of positive psychology, and health attitudes and behaviors has grown over recent years but is not well-integrated into contemporary mental health care in the medical setting.¹ In spite of the rising need for mental health care across the country, access to care remains a serious problem.

I hope this background will help contextualize my biases, observations, and recommendations.

The Current Status of HPM

Care delivery

We have made spectacular progress in building the field of HPM. Approximately 1.71 million Medicare patients were served by hospice in 2021, the most recent year for which public data are available, and 47% of Medicare decedents were enrolled in hospice at the time of death.² Over the past 20 years, we have seen wide penetration of palliative care programs into pediatric and adult care in hospitals, postacute settings, and the home. However, the overall improvement in access continues to show major disparities, with patients in the south and central regions of the United States, those cared for in safety net hospitals, and those cared for in for-profit settings having less access to HPM.³ Increasing evidence indicates that our system (including PC) may also be underserving family members, especially spouses of many patients with serious illness, a significant gap in access.⁴

Research

The field has developed a robust research base that is a critical part of its foundation for education and clinical innovation. A recent systematic review and meta-analysis showed that existing research does not demonstrate a significant effect of psychosocial interventions on distress. This article demonstrated numerous methodological and conceptual problems (including the exclusion of patients with existing mental health disorders!) in this body of work and concludes: “While psychological science and psychiatry have made strides in improving psychological distress symptoms, these advances have not been fully integrated into palliative care.” While this conclusion may turn out, even with better research, to be correct, our field appears to need inclusion of better mental health research expertise in our research programs.⁵

The good news, though, is that our colleagues are going to the literature frequently to better understand these issues, suggesting a need and a desire to improve their understanding of mental health issues. A machine learning analysis of the 100 most downloaded articles in the Journal of Palliative Medicine between 1999 and 2018 demonstrated that “understanding and managing the mental health needs of seriously ill patients and their families” was a top concern among journal readers.⁶

Education

Since its accreditation by the ACGME and ABMS in 2007, HPM has grown dramatically. In 2021, according to the American Academy of Hospice and Palliative Medicine, there were 8328 board-certified HPM physicians and 206 accredited fellowship programs in the United States. Table 1 shows the residency educational experience of our 8328 HPM-certified physicians. Fewer than 1% of HPM physicians are psychiatrists.⁷

Table 1. Residency Training Experience of HPM Physicians

	Number	Percentage
Internal medicine	5060	61
Family medicine	2033	24
Pediatrics	410	5
Emergency medicine	207	2
Anesthesiology	146	1.7
Surgery	86	1
Psychiatry	85	1
Obstetrics/Gynecology	80	<1
Neurology	75	<1
Radiology	70	<1
Physical medicine and rehab	69	<1
Preventive medicine	7	<1
AAHPM-Certified Physicians	8328	100

HPM, Hospice and Palliative Medicine.

The overwhelming majority of our fellows begin HPM training from residency with minimal, if any, training about mental health. And 99% of the HPM faculty physicians also have minimal, if any, training in the field. For the 61% of our fellows who come from IM, the ACGME Residency Requirements for Internal Medicine include no specific mental health training requirements.^8,9 While 24% of our fellows come from Family Medicine (FM), their residency requirements are very general—competency “to diagnose, manage, and coordinate care for common mental illness and behavioral issues in patients of all ages” and ability to “identify and address bio-psychosocial and spiritual dimensions of suffering in patients throughout the course of their illness…” and for experiences that are “structured so behavioral health is integrated into the residents’ total educational experience.” They are required to be “educated in the diagnosis of common mental illnesses.”¹⁰ While FM residents may bring some competencies into HPM, they are likely to be variable and general rather than focused on the complex needs of the seriously ill.

In addition to HPM fellowship training, HPM physicians educate medical students, residents, and fellows in other fields, and provide continuing professional development in our field. Because so many medical specialties care for people with serious illness, our cross-training of other disciplines is an important part of our mission to assure access to high-quality PC. Our teaching is effective and, among medical students and faculty, it has been shown to lead to learning improvements.^11–13 Our colleagues appreciate the value of our teaching to their learners and recognize the quality of our communication skills through personal interactions and at shared family meetings, team meetings, and conferences. They also note our relative comfort with challenging communication situations and what are sometimes perceived as “difficult patients.” They refer patients to us because of it.

Special issues in teaching about communication

PC emphasizes the importance of high-quality communication as a central element of clinical care and has made a major commitment to teaching communication skills through a variety of programs such as the Harvard Medical School Center for Palliative Care Program in Palliative Care Education and Practice, Vital Talk, the Serious Illness Care Program, and others. This has led to strong teaching about communication within our field and to our trainees. Communication competencies, which include such qualities as developing a therapeutic alliance and empathy, are essential elements of psychosocial care, but excellent communication skills uncoupled from psychosocial expertise can introduce challenges and, sometimes dangers, to patients and clinicians.

A skilled conversation can elicit information and emotions that the clinician does not know how to handle. Going too deep in a particular area (e.g., trauma) without understanding and experience in dealing with this level of vulnerability can cause psychological harm to the patient. A good communicator can elicit critically important diagnostic information that s/he does not recognize as such and misses a diagnosis. A clinician can be unprepared for the emotional dependency of a vulnerable patient on them and not adequately prepare the patient for an absence such as a service change. Our abilities to elicit deeper material from our patients are one of the strengths of our field. However, many clinicians have not had the training and supervised clinical experience to understand and appropriately address the issues we elicit. This lack of training and experience has potential consequences: not using elicited information as well as we could to inform care; inadvertently causing harm through our actions; and moral distress among ourselves that arises from feelings of helplessness and incompetence. Excellent communication is necessary, but not sufficient, to provide high-quality integrated clinical care. Our field has focused on teaching communication and, in large part, ignored teaching about mental health.

HPM fellowship training in mental health

The ACGME does not describe specific training requirements for HPM fellows in mental health, although a set of HPM Core Competencies have been proposed and endorsed by fellowship directors.^14,15 Based on recent work by Shalev et al., 95% of the mental health teaching is done by PC physician or nurse faculty. A 2023 study showed that most of the mental health training HPM fellows receive in fellowship is didactic; 98% of program curricula include mental health didactics. Didactics about delirium, substance abuse, depression, and anxiety disorders, as well as dementia, bereavement, and decisional capacity, were included in 84% or more of fellowship programs. In contrast, only 15% received teaching about personality disorders, 16% about serious mental illness, 21% about general psychotherapy, and 36% about trauma. Eighty percent of programs report that they do not have a single session on psychotherapeutic skills. Only 39% of programs offered a mental health elective and, of those, 74% responded that 0–10% of their fellows actually took the elective, which generally lasted 1–2 weeks. Interdisciplinary rounds is a key setting for teaching; there, mental health specialists were more present. About 95% of programs reported that rounds were attended by social workers, 24% by psychologists, and 9% by psychiatrists.¹⁶ Few HPM faculty have expert skills in evaluating mental health learning outcomes.

An instructive question presents itself: Would we consider having psychiatrists teaching about heart failure management, symptom management, and intensive care unit-focused PC to be a satisfactory approach to educating HPM fellows?

Non-psychiatrist-led training in mental health is not a desired state in our field. About 71% of HPM fellowship directors want to have enhanced access to psychiatrists, and 68% of HPM fellowship directors agree or strongly agree that involvement of a psychiatrist would be beneficial to their patients.¹⁶ Strikingly, fewer programs without psychiatrist involvement shared this view.

Perceptions of mental health care, comfort, and competency among HPM faculty

The majority of HPM physicians are dissatisfied with opportunities they have to learn how to care for patients with psychiatric comorbidities. Only 51% of HPM physicians were satisfied with the quality of mental health care received by their patients.¹⁷

In a national survey of HPM clinicians, 614 physicians reported an overall comfort level (on a 10-item, 1–5 Likert scale, 5 = very comfortable) of 34/50 in managing: delirium (5) depression (4), anxiety (4), dementia (4), agitation/aggression (4), substance abuse disorder (3), posttraumatic stress disorder (3), suicidality (3), schizophrenia (2), and personality disorders (2). About 80% reported that caring for patients with psychiatric comorbidities affected their comfort providing PC.¹⁶

Perceived inadequacy of mental health care in HPM is not limited to the United States. A cross-sectional study of hospice staff responsible for psychological services in the UK found that only 16% of respondents believed that care for their patients in their hospice was “wholly adequate.”¹⁸

Comfort, competency, and clinician well-being

Being responsible for providing care to patients without an inner sense of competence and comfort is likely to be stressful to physicians, who tend to value competency highly. Lack of confidence in communication skills has been found to be associated with burnout.¹⁹ Similarly, the physician’s sense of responsibility for providing high-quality care to a patient may be challenged by feeling incompetent to provide good mental health care, which can generate a form of moral distress—a form of tension between a moral and ethical obligation and obstacles that make the perceived correct path difficult to implement.

Self-perceived lack of competency can contribute to professional stress and burnout. In a convenience sample of AAHPM attendees at the Annual Meeting in 2023, 67% reported that, “frequently” or “often,” challenging patients with mental health issues contribute to distress/feelings of ineffectiveness/burnout (Poll Everywhere Data, from AAHPM annual meeting, 2023). While these responses require further study, they suggest that there may be a link between perceived burnout and the challenges of caring for patients with mental health issues without adequate training.

Research suggests that teaching psychosocial skills to PC clinicians increases their capacity to assess patients, intervene constructively, and use supervision appropriately in cancer patients with psychological distress.²⁰ Although a recent systematic review of the effects of communication skills training shows no benefit for clinician burnout,²¹ mindfulness-based interventions have been shown to have an impact on well-being.²²

Barriers to psychiatrist involvement in HPM within psychiatry

As a psychiatrist with more than 4 decades of incredibly rewarding experiences working in both psychiatry and HPM, I find myself perplexed by the disconnection between the two fields. I, like others, have observed and heard many potential barriers to collaboration:

•

The number of psychiatrists available to care for patients in the United States is significantly lower than the need. The current supply of adult psychiatrists, already inadequate, is expected to decrease 27% by 2030, in the face of a 6% increase in demand, leaving a shortage of 18–21,000 psychiatrists.²³

•

Psychiatrists are not interested in working in, or encouraged to work collaboratively with, HPM. Several sources corroborate and elaborate on this finding.^24,25 While consultation liaison psychiatry would be a natural partner for PC, in general, these two specialties function separately, administratively, educationally, and clinically. Anecdotally, PC clinicians frequently report difficulty engaging psychiatrists and psychologists with their patients. More research is needed to better understand the extent and reasons for this problem.

•

Mental health services nationally are underfunded, and patients, especially poor and minority patients, frequently lack access to mental health care.

•

HPM physicians frequently believe that they can manage patients with mental health needs without specialist input. This is undoubtably true for some clinicians with some patients. However, the variability in HPM fellowship training experiences and didactics, the self-assessed lack of competence, the difficulty in knowing what we do not know (sometimes called the arrogance/ignorance problem), as well as the prevalence of highly complex psychiatric patients undermine the validity of this belief in many cases.

•

Observations that the traditional psychiatric approach is not a good fit for HPM patients. This concern appears to derive from several issues: o

a correct perception that psychiatrists receive inadequate training in PC;

psychiatrists regularly report being uncomfortable caring for seriously ill patients;

an observation that psychiatrists’ practice is primarily focused on medication and does not utilize other modalities;

a concern that psychiatrists lack skills in relationship-building with seriously ill patients, partly from lack of experience and also from anxiety about caring for patients with severe illness;

a perception that the rigidity of the traditional psychiatric model with scheduled or one-off appointments does not work for patients with unpredictable serious illnesses.

Interdisciplinary teams

Only 10% of HPM fellowship directors report that psychiatrists or psychologists are regularly involved in interdisciplinary team rounds.¹⁶ Clinicians widely perceive inadequate access to specialized mental health services.

Social workers are obvious experts. They are present on most PC teams and have expertise in psychotherapy, family dynamics, care coordination, and community resources. Although they provide education on psychosocial topics, particularly at the bedside with fellows, clinical demands are usually very high, and there are rarely a sufficient number of social workers with support for robust educational roles on the team. Social workers not only have some overlapping expertise with psychiatrists and psychologists but also have a distinct set of complementary competencies. Funding models to pay mental health clinicians for teaching non-mental health clinicians are inadequate.

NPs and PAs have some expertise in this domain but rarely have specialist-level training. They play critical roles in the provision of palliative care in hospitals, postacute settings, at home, and in rural areas. They represent a major underdeveloped resource for psychosocial care and teaching.

Finally, because of the nature of learning and modeling, effective integration of appropriate responsibility for an integrated medical-psychosocial approach to clinical care requires physician role models who have expertise in this area; this remains a limiting factor.

Mental health issues in PC

Since 2020, rates of mental illness among U.S. adults have risen. About 23–41% of American adults experienced some kind of psychological distress during this time (note that these data derive from the time during and since the COVID-19 pandemic).

Percentage of U.S. adults with:
Psychological distress	23–41%^26–28
Depression/bipolar illness	7–11%²⁹
Anxiety	13–20%³⁰
Posttraumatic stress disorder	4–5%³¹
Substance abuse	17%³²
Suicidal thoughts	5%³⁰
Borderline personality disorder	1.4%³⁰
Serious mental illness	4.5%³³

Patients with serious illness have a higher prevalence of mental health distress and disorders than the general population. About 35–40% of patients with cancer have a diagnosable psychiatric illness.³⁴ As many as 27% of patients with end-stage renal disease experience depression,^35,36 as do 20–40% of those with Parkinson’s disease.^37,38 Among patients with heart disease, 17–45% of patients have depression or anxiety disorders.^39–41 In addition to these elevated rates of mental health disorders among patients with serious illness, our subspecialty colleagues appear to preferentially refer these patients to PC.⁴² Studies conducted within PC services suggest that rates may be significantly higher than these non-referred baselines. Among Japanese patients seen by PC, 70% fulfilled criteria for a psychiatric diagnosis (28% delirium, 18% adjustment disorder, and 8% major depression).⁴³ Among ICU patients with cancer referred to PC services, 81% were found to have delirium, and 65% to have anxiety.⁴⁴

The high burden of mental health disorders, including substance abuse and trauma disorders in the general population, amplified by recent social changes (pandemic, loneliness, and social media), the negative impact of serious illness on psychological well-being, elevated referral rates of patients with mental health disorders to PC, and acute psychiatric issues (e.g., delirium, anxiety) that accompany the approach of death, suggests that as many as 40–75% of the patients we see in HPM are likely to have a mental health disorder or severe psychological distress.²⁵ Generalist mental health competencies are insufficient to care for the population of patients we see in PC.

Can we meet this level of need for mental health care in our clinical work with our current uneven didactic curriculum, small number of participating psychiatrists and psychologists, and our current non-expert training faculty? I believe not. We need to elevate our practice and our teaching to meet the needs we are being asked to serve and to fulfill our commitment to “whole-person care.” To do this, we will need to identify ways to better learn from and collaborate with our psychiatry and psychology colleagues, to support expanded teaching roles for our expert social workers, and to undertake reflection and learning about our biases toward people with mental health issues and to learning about mental health.

Confronting mental illness biases in PC

Distressing as it is to see and acknowledge, the field of PC, like the rest of medicine, has a negative bias about the importance of mental health in quality of life and in clinical care. In spite of the high prevalence of mental health disorders and psychological distress, PC has failed to navigate these issues, as argued above, in clinical care and education. Several factors are likely to be involved. First, like most human beings, and perhaps particularly those in medicine, we stigmatize people with mental illness (including ourselves). Stigma is defined as an “attribute that is deeply discrediting.”⁴⁵ Second, many persons with mental illness are challenging for their clinicians to manage and may exhibit behaviors, such as emotional instability, anger, fearfulness, and unusual thoughts that evoke discomfort in clinicians. Third, clinicians without a mental health background lack cognitive maps and concepts that allow them to contextualize these behaviors. And, fourth, many of these patients are inherently challenging to help in ways clinicians are accustomed to helping and may generate a sense of helplessness in the clinician.

Our lack of understanding, aversion to unusual behaviors, and fears of violence, unpredictability, and weakness among people with mental illness contribute to stigmatizing behaviors by professionals, including distancing, labeling, stereotyping, and discrimination.⁴⁶ Research demonstrates that patients with mental health issues regularly report stigmatizing interactions with health care professionals, including psychiatrists.⁴⁷ More than 20 years ago, Jimmie Holland, MD, the founder of the field of psychooncology, highlighted the role of stigma related to mental health disorders in the care of patients with cancer.⁴⁸ In general, PC has recognized “challenges” in caring for people with substance use disorders and chronic pain,⁴⁹ but I am unable to find articles addressing the issue of stigma related to other mental health disorders in PC.

This bias affects our research. Our research outcomes for non-symptom interventions, particularly in the realm of communication, focus on goal-concordant care, satisfaction, preparedness, prognostic awareness, and coping and omit psychological well-being, anxiety, and depression, which are critical patient-centered outcomes.⁵⁰

A variety of interventions have been proposed to address this problem. Many of these interventions are based on the concept of “reflective practice” as described by Donald Schon in his 1983 book “The Reflective Practitioner.”⁵¹

HPM clinicians would benefit from specific learning about how to effectively make a patient-centered, nonthreatening, nonstigmatizing referral to a psychiatrist or psychologist. Many patients who would benefit from treatment do not receive that treatment because the referral did not address their concerns or because the visit increased feelings of stigma and diminishment.⁴²

Because of our professional focus on empathy, individualization, and whole-person care, it may be more difficult for us, as PC clinicians, to recognize and address our biases. Just like many of our oncology colleagues, early on in the development of our field, expressed the feeling that “we already provide excellent palliative care to our patients,” we may also be asserting that “we already provide excellent care to people with mental health issues.” And both statements are true, to some extent. We need to address our biases and improve our competencies to meet the needs of our most complex patients.

Moving toward improvement

While education can contribute to changes in clinician behavior, sustained and systemic change requires changes in the cultures within and outside HPM. The “beliefs, norms, values, and practices that guide behavior” are powerful forces in this kind of change.

Cultural and system factors within medicine that contribute to lack of integration are many and include: •

Disciplinary silos exist, which reduce opportunities for relationships, cross-fertilization, and trust.

•

Since most HPM divisions or programs live in IM, and the majority of clinicians in our field come from IM, the culture of HPM is heavily influenced by the values, beliefs, and practices of IM. The dominance of the biomedical model within most of medicine contrasts with the more ecumenical emphasis on physical, emotional, spiritual, and social quality of life in HPM.

•

Since its inception, HPM has been, in many ways, a countercultural force in medicine, with a different approach and set of values and practices (e.g., focus on interdisciplinary collaboration, he role of the family in care, “whole-person care,” and emotions). Many of these elements of culture elicit ambivalence in our colleagues and sometimes in us.

•

Stigma exists broadly against mental illness and psychiatry is frequently devalued within medicine.

•

Increasing corporatization of medicine which overemphasizes “throughput” and “efficiency” and underemphasizes caring, leading to increased time pressures and burnout, cynicism, and dissatisfaction among physicians.⁵²

•

Poor reimbursement for mental health services, which creates more financial burden on HPM programs that provide these services.

•

Broken health care system with increasing fragmentation, leading to diminution of the doctor–patient relationship and longitudinal care.

•

Catastrophically broken mental health system due to underfunding, understaffing, and embedded inequities.

•

Uneven implementation of psychosocial distress screening, leading to inconsistent diagnoses and treatment of people with psychological disorders.

•

Ambiguity and confounding between psychosocial and spiritual care and lack of a clear consensus about responsibility and key competencies.

•

The “arrogance/ignorance paradox”⁵³ in which clinicians do not know what they do not know. This is common throughout medicine, and especially in new disciplines where clinicians may feel that “we already do that” but may not recognize the limitations of their own knowledge. In our field, it can take the form of an assumption that “psychological support,” which we often provide, is adequate mental health treatment for multiple problems. Most HPM clinicians lack awareness of other treatment modalities, how to use them, and what their benefits and drawbacks are and thus contribute to lack of access to state-of-the-art mental health care for our patients.

Changing culture

In addition to education, systems changes and culture change are necessary to assure wide, deep, prolonged adoption of changes in clinical practice.⁵⁴ Many general principles that underlie culture change have been described, including some related specifically to PC change-making. These are briefly reviewed and highlighted below.

Visible commitment from leaders

Direct engagement from leadership with concrete actions that demonstrate engagement, such as visible changes in personal professional practice (leaders adopting new behaviors), leading process changes that facilitate new behaviors (e.g., hiring of mental health clinicians by PC programs), and developing and reporting performance metrics that relate to desired changes (e.g., process measure of number of patients seen by social work, psychology, and psychiatry; outcome measures of family satisfaction with care, patient quality of life, anxiety, depression, or clinician work satisfaction).

Ongoing communication and problem-solving about progress, barriers, and new initiatives

In addition to top-down communication, change is facilitated through input and collaboration among key stakeholders. Input from frontline clinicians about clinical challenges, systems problems, etc. is critical to change initiatives focusing on high-value interventions and to refinement of these strategies. While it might be valuable for leaders to set targets for HPM/psychiatry collaborative encounters, input from both disciplines about what led to meeting or not meeting quality-of-care-focused goals will lead to better solutions and dissemination of best practices.^55–58

Assessment of challenges and resistance to culture change within the institution

Each institution has unique barriers to integration of HPM and mental health. Careful “diagnosis” of the nature of the barriers will allow targeted change strategies that optimize success. Since HPM and psychiatry have different cultures, change strategies and the structure of the collaboration need to be aligned with both the cultures and missions of both disciplines. Any integration effort will need to understand and develop a plan for some form of blending of the two disciplinary cultures in the service of clinical care. Different models for collaboration exist and need to be evaluated in relation to existing structures and culture.⁵⁹ For example, in a program where institutional funding for mental health clinicians is not available, fundraising may be a critical success factor; in another context, in which there has never been a connection between HPM and psychiatry, the critical tactic might be for leaders of HPM and psychiatry to develop a relationship.

Allocation of resources and personnel to support changes

On-the-ground efforts and resources will be required to plan and implement this integration process. Engagement of stakeholders and an interdisciplinary steering group, involving clinicians at all levels in HPM, psychiatry, psychology, social work, chaplaincy, patients, and administration, will be required. In addition, clinicians from medical subspecialties who care for seriously ill patients will require input into changes. Since resistance to change is a universal aspect of the change process and requires ongoing management and problem-solving, a structure for addressing this barrier (e.g., an advisory or steering group) would ideally be convened to facilitate change.⁶⁰ Both short- and long-term planning is necessary. For example, if appropriately trained personnel can be repurposed or hired, relatively quick implementation will be possible; in some cases, where no psychiatrist/psychologist is available, a long-term commitment to training such individuals for work in HPM might be necessary.

Strengthening, expanding, and innovating in interdisciplinary team care delivery to assure clarity of roles and appropriate processes for mental health input

Because of overlaps and gaps in roles of mental health and PC clinicians, responsibility for mental health care is often diffuse or unclear. Current referral processes for mental health care are generally ad hoc and variable. Collaborative care models, such as those developed in primary care to offer care to patients with mental health and primary care needs, have demonstrated positive effects on outcomes.⁶¹ This model has showed promise in oncology⁶² and, more recently, in PC;⁶³ further innovation and adaptation have potential to enhance integration.⁶⁴

Multiple simultaneous change strategies focused on both the individual and the system

Because culture “lives” in attitudes, values, structures, and processes within organizations, change strategies need to be broad-based. A combination of key changes such as an available psychologist and/or psychiatrist to see patients; enhanced fellowship teaching about psychological issues in PC, including didactics; individual supervision with a mental health clinician; regular conferences focusing on mental health issues, including clinician experiences and countertransference; use of structured assessment measurement for distress, depression, and anxiety; and inclusion of a structured form for recording information about mental status, substance use, etc. would reinforce attention to this area.

Attend to equity and diversity in change management

The communities that are served by the institution and the workforces available to provide care in both HPM and psychiatry should be central considerations in the change process. Access to services, clinician background, language, and education all require attention.

Development of appropriate, focused educational opportunities for trainees

We need to refine HPM fellowship competencies related to psychosocial care in collaboration with mental health experts and clarify the boundaries of the PC clinical role for the non-mental health clinicians on the team. Teaching about the unique aspects of making a successful mental health referral should be included. Involving both HPM clinicians (including, of course, social work) and psychiatrists/psychologists will be essential to develop a focused curriculum aimed at HPM. Classroom teaching and supervision by non-mental health experts alone are inadequate.

Intensive self-reflection addressing beliefs and practices related to mental health

Attitudes and beliefs are both significant contributors to resistance to change and also provide helpful cues to implement change successfully. Finding the balance between working with and through resistance and creating change in negative attitudes, like stigma, are a critical element of success in achieving change.^65–67

Faculty development/capacity building

Faculty development for HPM educators will be necessary to assure that faculty are supporting and encouraging, rather than undermining, new learning about mental health issues. Faculty have the power to teach and to unteach; implementation will be more successful if HPM faculty are taught by psychiatry faculty to role model new behaviors (e.g., teaching about stigma, mental status evaluation and documentation, personality disorders, basic psychotherapeutic skills, managing patients with serious mental illness, countertransference, etc.), ask for help from mental health experts, and reinforce teaching received by learners.

Ongoing assessment of progress with feedback to participants

Development of quality indicators for enhanced integration (e.g., proportion of patients with structured mental status evaluation; substance use risk, GAD-7 anxiety assessment, PHQ-9 depression scale, documented in electronic health record; number of referrals to mental health; clinician well-being; and self-assessed competence and comfort) can serve as meaningful outcomes to track change over time.

Opportunities for collaboration with psychiatry and psychology

Each institution will encounter its own challenges in collaboration between HPM and psychiatry/psychology and will need to discover its own solutions. Several strategies might be considered. In general, a strategy of “partnering when we can”—with departments, training programs (e.g., Consultation-Liaison Psychiatry), and individuals —is likely to represent the best model. Faculty development of both HPM and psychiatry/psychology faculty to learn how to collaborate, and to learn from each other, will help to build a common foundation for future work. Developing systems for access to psychiatry and psychology referral/consultation that meet patient and clinician needs is critical and will require relationship building with colleagues in these disciplines. Collaborative teams, including ongoing joint educational programs among trainees, faculty, and staff between mental health and HPM, will strengthen relationships, problem-solving, and learning. Other collaborative opportunities are outlined in detail elsewhere.⁶⁸

New guidelines for inclusion of psychiatry or psychology as core members of the HPM team

The prevalence and challenges of mental health issues in HPM are clear. In order to both care for these patients and educate our clinicians about mental health, consideration should be given to requiring a psychologist or psychiatrist on all HPM interdisciplinary teams.

Capacity building

One of the biggest barriers in providing integrated HPM/mental health care is the shortage of mental health clinicians. One approach to countering this impediment is to actively recruit HPM fellows with residency training in psychiatry to expand the diversity of our HPM workforce and enhance the focus on mental health issues. We now have a critical mass of 85 HPM-certified PC/psychiatrists who can be key advocates and leaders in this interdisciplinary process. The field should consider developing its own interdisciplinary academy of integrated HPM/psychiatry teaching, with expertise in psychiatry/psychology, HPM, and medical education to support this mission and assure widespread national professional development opportunities for clinicians in our field. Collaboration between AAHPM and the American Academy of Consultation Liaison Psychiatry could enhance and broaden these efforts. One of the most effective practices to rapidly enhance faculty teaching capacity has proven to be national interfaculty development courses that allow even small programs to build skills of their HPM clinicians.

The need for research on care of HPM patients with comorbid psychiatric disorders

More attention to the clinical mental health challenges and needs of our patients will enhance the sophistication of our research questions, methods, and outcomes through closer collaboration and interdisciplinary sharing of research methods. Including PC patients with mental health disorders in our research will allow us to improve approaches to this growing, and often-challenging, population of patients.

Implementation challenges

Addressing the needs described here will require synergy, not just across disciplines, as described above, but among institutions, organizations, and funders. It is unlikely that individual programs will be able to achieve the goals described above without collaboration structures that connect them with other programs. Here, the AAHPM could play a major role as a convener, facilitator, and advocate. The American Board of Hospice and Palliative Medicine is responsible for setting educational and practice standards for the physicians in the field; its fellowship requirements may influence and be influenced by changing ideas about the role of mental health education in HPM. Change is likely to be facilitated by engagement of psychiatry leadership and organizations, especially from Consultation-Liaison Psychiatry through the American Academy of Consultation Liaison Psychiatry, in exploring new care and education models that could meet needs in both fields and generate new research collaborations. Finally, funding and supporting this integrative work will require substantial resources. Developing telemedicine resources, improvements in health information technology, quality measures, better integration with community-based services (e.g., hospice), and the development of focused psychosocial interventions are promising areas that could facilitate implementation. Strong collaborations between HPM and psychiatry in developing care models for patients with both medical and mental health serious illness could be highly attractive to funders.

Benefits of mental health integration for our patients and our field

The changes suggested here represent a next step in respecting, enhancing, and institutionalizing “whole-person care” in HPM, a goal which has not yet been realized. Patients with a serious illness inevitably experience diverse psychological consequences of their illnesses, and a growing number bring psychological vulnerabilities, including mental illness, to their illness experiences. It is essential that our clinicians develop and practice the competencies to address these aspects of the patient experience. It is what we all want for ourselves and our loved ones.

In addition, moving forward with this agenda has the potential to support our entire workforce in feeling more comfortable, competent, satisfied, and effective and to decrease the problem of burnout among our colleagues. Our learners and colleagues are starving for help with these issues, and we will be better able to meet this need. Reaching closer to the goal of providing whole-person care has the potential to inspire our learners and better support our colleagues. Finally, we can be a symbol, a model, and a vehicle for whole-person care for the rest of medicine as so much of our health care system slides away from it.

This article is based on a presentation given as the inaugural Alyssa L Bogetz Educational Fund Lecture at the American Academy of Hospice and Palliative Medicine Annual Assembly in Montreal, Canada in March 2023. I am grateful to the Bogetz Family for their support and inspiration in preparing these ideas.

The countless patients and families I have cared for, as well as the students, residents, fellows, faculty, and other clinicians with whom I have had the privilege of working over the past 40-plus years have taught me and inspired these ideas.

I acknowledge, with respect and love, the 34-year collaboration with my late husband, Andy Billings, who was my partner in developing many of these ideas.

Footnotes

Author Disclosure Statement

None to report.

Funding Information

None to report.

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