Attending to the “Mental Suffering” of Patients With Progressive Medical Illness

Since people with progressive, life-limiting illnesses experience distress in many domains, effective care in this context often requires a comprehensive and interdisciplinary approach. Palliative care is now broadly recognized as an essential treatment model in this scenario. As exemplified by the case vignette, as well as by the description in the epigraph of Ivan Ilych’s “mental sufferings,” serious psychiatric and psychological symptoms frequently accompany a life-threatening illness, and psychiatric expertise is often an important component of the care plan. In fact, as the field of palliative care has matured over the past decade, there has also been significant growth in the development of palliative care psychiatry as a sub-field bridging these two disciplines. As a result, psychiatrists have found ways to bring their expert skills and knowledge to the care of medically ill patients who are nearing the final phase of life. CASE VIGNETTE Several years ago, in your first contact with Carla, you diagnosed MDD. Her treatment included sertraline and weekly psychotherapy with a psychologist colleague. She eventually achieved a full remission. By mutual agreement, the medication was tapered off, and she stopped seeing you but continued with the therapist, with an understanding that you would be available to reconsider medication if her depression recurred. Carla returns to your clinic after an absence of more than a year. Her psychologist and primary care physician both spoke to you briefly before the visit; they shared concerns that Carla’s depression has returned, noting that Carla recently received some bad news. Carla seems relieved to see you, although you sense that she is preoccupied. Through tears, she shares the bad news your colleagues had alluded to: she has metastatic lung cancer, which, her oncologist says, is likely to take her life within a year. Most of the encounter is focused on making sense of the new uncertainty about her future: Why me? Why now? What’s going to happen to me? Naturally, she acknowledges feeling distressed and depressed, but she asks angrily, “Isn’t it normal for me to feel this way?” You do your best with her questions, mostly providing a supportive presence and the reassurance that you will help as much as possible. You are glad to have been consulted again, but you have questions of your own. You wonder: Is this a normal response? How can I distinguish between clinical depression and the grief that accompanies a frightening diagnosis with a devastating prognosis? If she is clinically depressed, will treatment be helpful this time? What should I anticipate as the cancer progresses in terms of psychiatric distress? Will there be a role for me in her care, and how will I interface with her cancer care team? How will I be affected as she nears the end of her life?