Table 3.

Final Consensus Competencies in the Category of Psychiatric Disorders in Serious Illness^a

B. Psychiatric Disorders in Serious Illness:
1. Principles of assessment and diagnosis:b
a. Transdiagnostic concepts and skills
i. Assess capacity to make medical decisions using the set criteria of a patient’s ability to: 1) communicate a consistent choice, 2) understand the information relevant to the decision, 3) appreciate the consequences of the decision, and 4) manipulate the information and involved consequences to arrive at their choice, even if not in the way others might.
ii. Identify psychiatric emergencies such as acute suicidality and agitation/aggression and partner appropriately with mental health specialists in management.
iii. Use universal precautions for opioid use disorder in opioid prescribing (e.g., routinely checking the state prescription drug monitoring program, using pain agreements, and obtaining periodic urine drug screens).
iv. Implement strategies to minimize negative consequences of substance-use among patients on controlled substances and/or with substance use disorders (Concepts: harm reduction and risk mitigation).c
v. Provide high quality palliative care to people with serious medical illness who also have serious mental illness, personality disorders, substance use disorders, and/or neurodivergence, in collaboration with mental health specialists
b. Psychiatric disorders:
i. Diagnose and provide first-line management for uncomplicated presentations of the following psychiatric conditions among patients with serious illness, as appropriate in your practice setting:
a. Major depressive disorder
b. Generalized anxiety disorder
c. Adjustment disorders
d. Delirium
e. Opioid use disorder
ii. Recognize and refer to mental health specialty care
a. Complex or treatment-resistant forms of the above conditions
b. Nonopioid substance use disorders
c. Prolonged grief disorder
2. Interventions:
a. Psychopharmacology:
i. Select psychopharmacologic agents for patients with serious illness with consideration of medical context (i.e., prognosis, metabolic considerations, potential drug interactions, available routes of administration, pill burden, side-effects), and potential physical symptom benefits (e.g., olanzapine for nausea, mirtazapine for sleep, SNRI for neuropathic pain)
ii. Safely and appropriately use selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and mirtazapine for treatment of depression and anxiety among patients with serious illness and depression and/or anxiety.
iii. Safely and appropriately use benzodiazepines for treatment of anxiety among patients with serious illness.
iv. Safely and appropriately use antipsychotics for the management of agitation in delirium.
b. Psychotherapy
i. Demonstrate the ability to offer therapeutic presence in the setting of distress
ii. Use nonjudgmental, open-ended questions to elicit motivations among patients navigating behavioral change or medical decisions (Psychotherapeutic modality: Motivational Interviewing)c
iii. Tailor palliative care interventions, including serious illness communication, to patients’ and caregivers’ affective state and coping capacity (Psychotherapeutic modality: Trauma-informed care; Concept: Attunement)c

^aThis section is for common situations that extend beyond typical coping. Psychological reactions become psychiatric concerns when they are severe, persistent, and significantly impair a person’s ability to function in daily life. Psychological reactions, like sadness, worry, or stress, are normal responses to life’s challenges and changes. However, when these reactions are intense, last for a prolonged period, and interfere with activities such as work, relationships, or self-care, they may indicate a psychiatric disorder. All palliative care physicians should have competence providing first-line therapeutic interventions on these disorders while also recognizing one’s practice limitations.

Note: All of the concepts and skills noted in section A continue to be relevant when working with patients who are experiencing a mental health disorder.

^bOrganizational headings are indicated in italics.

^cNote: we have listed psychotherapeutic modalities and psychological concepts as key terms to direct physicians’ further reading/learning, not as an indication that the concept is fully captured in this competency.