Realizing the Imperative: The Future of Mental Health and Palliative Care Integration

Improving Access to Mental Health Training for Palliative Care Clinicians

PC teams are increasingly expected to provide mental health care for those without access to specialist mental health services. ¹ As Dr. Block highlights, PC physician fellows receive limited training in mental health. ² Most PC clinicians report dissatisfaction with training opportunities in mental health. ¹ Fortunately, low-resource, highly scalable training methods can increase PC clinicians’ self-efficacy in managing mental health concerns. ³ Webinars, presentations at national meetings, and journal articles focused on mental health-related topics are well-received and highly utilized.^4–6 However, there is a lack of field-wide competencies and scope of practice in mental health to guide broader adoption. ⁷ There is a need for professional organizations such as the American Academy of Hospice and Palliative Medicine to align and guide the development of disseminable and scalable training opportunities in mental health across a range of domains (see Table 2). Such initiatives must extend beyond physicians to other interdisciplinary team (IDT) members, such as chaplains whose existing skills lend themselves to further mental health training.

Empowering Palliative Care Social Workers

Social workers are frontline psychosocial clinicians on PCIDTs. However, their expertise is often underappreciated or devalued. Social workers are expected to serve in multiple critical roles, including supporting medical decision-making, addressing social determinants of health, and case management. ⁸ This breadth may prevent social workers from focusing on mental health care. The recent implementation of the Advanced Palliative Hospice Social Worker - Certified credential and its adoption by the Hospice & Palliative Care Credentialing Center are important steps in codifying the expert scope of PC social workers. ⁹ Yet, systemic barriers undermine PC social workers, specifically the lack of reimbursement for many social work services and meaningful opportunities for PC specialty training. ⁸ Expansion of social work reimbursement and specialty PC social work training programs are key steps in advancing the field.

Developing Palliative Care Psychology, Psychiatry, and Psychotherapy

Trainees in psychiatry, psychology, and psychotherapy (including non-PC social workers) often lack exposure to PC.^10,11 As a result, few mental health clinicians access specialty PC training or work in PC settings. Although mental health clinicians must provide primary PC to patients in psychiatric settings, primary PC interventions have not been adapted to their needs.^12,13 Collaboration is needed to develop pathways for dual-trained clinicians to bridge the silos, educate the broader mental health workforce about PC, and participate in integrated care programs. ¹⁴ Such pathways must include integrating early PC exposure for mental health clinicians (e.g., rotations in PC for psychiatry and psychology trainees) and formalized recognition of the unique skills and knowledge of PC psychiatry/psychology subspecialists through accreditation and certification.^15–18 In the interim, fostering local collaboration between mental health specialists and PC programs can immediately improve care for patients on both sides of the divide

Advancing Integrated Palliative Care and Mental Health Models

Like PC, mental health care benefits from an interprofessional lens. Capacity to address the mental health needs of patients with serious illnesses can be improved by expanding the IDT to include psychiatrists and psychologists—specialists who can work synergistically with social workers to provide mental health care. Several coauthors of this editorial provide specialty mental health expertise within PC, a model exemplified by Dr. Block. ⁴ However, given limitations in workforce and resources, such models are not scalable. In primary care settings, integrated care models, such as collaborative care, allow interprofessional mental health specialists to provide stepped care at a population, rather than individual, level. ¹⁹ Thus far, efforts to adapt such models to the PC setting are limited.^20,21 Federal agencies, professional organizations, and philanthropic partners must prioritize funding to support developing and implementing evidence-based integrated care models that extend beyond oncologic PC and include caregiver mental health and bereavement services, given our field’s focus on patients and caregivers.

Integrating a Rigorous Mental Health Lens into Palliative Care Research

Much of the research in our field fails to describe or measure the mental health components of PC adequately.^22,23 Furthermore, intervention research in PC has largely focused on PC as the intervention, with minimal exploration of mental health interventions within the PC setting.^24–27 This gap is significant because psychiatric research is often conducted in medically healthy individuals. As such, the evidence base for assessing and treating mental health disorders in serious illness remains underdeveloped. For instance, a recent expert consensus on symptom management for patients with cirrhosis identified no specifically tested pharmacological interventions for anxiety or depression in this population despite these being core target symptoms. ²⁸ The use of many psychosocial screening tools ²⁹ and psychopharmacological interventions in PC are based on inferences from research that excludes patients with serious illnesses. Furthermore, those interventions studied in the serious illness population, such as work addressing psychological distress in psycho-oncology, are not widely deployed and accessible because of lack of evidence about or resources for scaling and dissemination. Our field—and funders—must invest in research that rigorously assesses mental health outcomes in PC and that adapts, designs, and implements mental health for patients with serious illnesses.

Advocating for Equity in Serious Illness Care for Individuals with Mental Health and Substance Use Disorders

Patients with mental health disorders—particularly serious mental illnesses such as chronic psychotic disorders and substance use disorder (SUD)—experience care inequities in multiple domains of serious illness care. PC clinicians report feeling poorly equipped to manage this population, and systemic reform is needed to integrate SUD treatment into PC.^30,31 Recent guidelines, such as those addressing integrated care for SUD and serious illness, represent an important first step toward ensuring equitable, evidence-based care.^32,33 However, to best address the needs of patients with serious mental illnesses and/or SUD, there is a need for both novel evidence-based models of care and support to implement such models. Of particular note, given the interface between trauma and SUD/serious mental illness, PC programs must adopt trauma-informed approaches to serious illness care. ³⁴

We thank Dr. Block for highlighting this critical gap in our field. This is our moment to fill these gaps and build aspirational care models. We urge our colleagues to advocate for policy changes prioritizing mental health integration in PC settings, develop educational initiatives to enhance our field’s competencies, and actively engage with mental health professionals to expand patient-centered access to equitable care. Indeed, broad, meaningful collaboration is the only way we can live up to Dame Saunders’s and Dr. Block’s imperative that we provide care across the physical, psychological, social, and spiritual domains for those in need.