What Do Psychiatrists Think About Caring for Patients Who Have Extremely Treatment-Refractory Illness?

Abstract

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments.

Keywords:

• Futility
• mental health
• palliative care
• psychiatry
• suicidal ideation
• treatment-refractory mental illness

This article is referred to by:

What Is Futility in Psychiatry?

On Changes and Opportunities at AJOB Neuroscience

Treatment-Resistant Psychiatric Conditions and the Ethics of Psychiatric Physician-Aid-in-Dying

Hope in the Face of “Futility”: Considering the Full Scope of Psychiatric Treatment Options

Psychiatric Care When Cure Is No Longer the Goal: A Call for Expansion of Management Options for Treatment-Resistant Mental Illness

Humanizing Patients and Their Needs Might Affect Psychiatrists’ Thinking about Futility

ACKNOWLEDGEMENTS

The authors would like to thank Oprah Garrett and Meredith Trejo for administrative assistance with the study. The authors would also like to thank Roxanne Bartel, Wilbur Dattilo, and Benjamin Lewis for their assistance in reviewing the cases presented.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by a Greenwall Foundation Faculty Scholars Program Fellowship (BMK). The Greenwall Foundation also funded the Philosophical Bioethics Seminar Series where the study team discussed many of the normative issues prompting this study.