Where is the limit?
In psychiatry, there are often no well-defined endpoints for treatment, especially in the most severe cases. How long should a therapy last, and when is the patient well enough? Some of the treatment guidelines include proposals for the duration, such as 16–20 hours of psychotherapy for moderate to severe depression, but for most severe conditions, the recommendations are vague and refer to 'adaptation' (13). Since the expectations for mental health care tend to be comprehensive and diffuse, and include treatment of the person's overall life view, often within the foreseeable future, conflicts arise. Unclear expectations and unclear guidelines tend to result in media reports claiming that the treatment was terminated prematurely (14).
A worsening of COPD is treated by stabilising the temporary exacerbation, and the treatment is considered successful even if the patient returns after a couple of months with a further exacerbation. If a psychiatric patient is treated with the same intensity, but suffers a relapse after a couple of months, the psychiatric treatment will quickly be considered to have failed. In the media, such cases are frequently referred to as psychiatry's 'revolving-door patients' (14, 15). This type of condescension is rarely applied to somatic patients. The premise for these narratives is that it is not the disorder that causes the lack of improvement, but the inadequate treatment provided to the patient. There seems to be little acceptance of the fact that mental disorders may also be chronic.
In the healthcare service we go to great lengths to prolong life and thereby postpone death. However, we also see illusions of a vision zero for deaths in psychiatry – and for suicides in psychiatry, in particular. It has never been a question of whether we will die, only when and from what. In Norway, more than 40 000 people die each year. Why has it been made an explicit goal that all these deaths should be attributable to somatic causes? A vision of zero psychiatric deaths is only rational if all psychiatric deaths de facto could have been avoided. Unfortunately, this is not so.
A vision of zero psychiatric deaths is only rational if all psychiatric deaths de facto could have been avoided. Unfortunately, this is not so
Over time, palliation has become a meaningful and important part of medical practice, as formulated in the well-known aphorism 'cure rarely, comfort mostly, but console always' (16). On the other hand, there is little tolerance for enough is enough for psychiatry. Nor are there any options for psychiatric palliation. The latter would require acceptance of the fact that even psychiatric disorders can be intractable and terminal. In somatic medicine, futile treatment tends to be discontinued. Such termination of life-prolonging treatment with limited benefits and a potential for harm is referred to as limitation of treatment (17). When futile or harmful treatment in psychiatry is discontinued, however, media reports give us headlines such as 'denied a second chance' – as if psychiatry wishes to kill its patients (18).