For a vast majority of psychiatrists in India, suicide prevention in patients with severe and persistent mental illness (SPMI) was very important. Psychiatrists in India also tended not to view SPMI as a terminal illness with 26.7% even strongly disagreeing with this notion. However, curing the illness was not very important for the majority, and some psychiatrists in India even regarded further curative treatment as futile in specific cases. Almost all psychiatrists emphasized the importance of reducing suffering and of functionality of SPMI patients in everyday life, both of which are central concepts in palliative psychiatry (8, 10). Consecutively, a majority believed that palliative psychiatry is indicated for some patients with SPMI (especially schizophrenia), even in the absence of a life-limiting somatic disease. However, when confronted with vignettes of specific patients with severe, chronic, and therapy-refractory schizophrenia and depression, most psychiatrists in India indicated that they would not be comfortable with improving quality of life at the expense of life expectancy.
At first glance, this strong emphasis on both duration and quality of life of SPMI patients may be difficult to reconcile. However, palliative psychiatry can be accommodated alongside a curative approach, and as the disorder does not need to be terminal for the application of palliative psychiatry (8), it does not necessarily mean discontinuing curative treatment (6). In line with this interpretation, only a minority of surveyed psychiatrists in India found that the term palliative directly relates to end of life.
Comparison of psychiatrists’ attitudes in India and Switzerland
The participating psychiatrists in India tended to support both curative and palliative approaches for patients with SPMI more strongly than psychiatrists in Switzerland. Regarding curative approaches, psychiatrists in India considered it more important to impede suicide and to cure patients with SPMI than psychiatrists in Switzerland. In line with these attitudes, psychiatrists in India were less likely to believe that SPMI can become a terminal illness. The same trend is apparent in both case vignettes; psychiatrists in India would be more surprised if the patient with severe and persistent schizophrenia or recurrent major depressive disorder would die within the next 6 months. They were less likely to consider further intervention futile in both cases than psychiatrists in Switzerland, and they would not be comfortable with a reduction of life expectancy in either case, even at the expense of quality of life.
How might we explain the stronger support for curative approaches and suicide prevention in SPMI of psychiatrists in India? First, as referred to in the introduction, it is considered important not to classify patients as chronic or therapy-refractory because of insufficient treatment and resources; on that basis, a curative approach should not be abandoned (6). As psychiatrists in India are likely very aware of this issue, they may therefore tend to favor a curative approach even for patients classified as suffering from chronic, severe, and therapy-refractory mental disorders.
Second, although suicide rates in India are generally comparable to Switzerland (30), in persons aged between 15 and 49, suicide rates in India are almost twice as high as in Switzerland (31). Vijayakumar (29) reported that more than 70% of suicides in India involve persons younger than 44, which is the age range in the case vignettes. In a comparative study of attitudes to suicide among medical students in India and Austria, overall attitudes were more negative in India, and suicide was associated with mental illness, cowardice, and even illegality (32). In India, attempted suicide was only recently decriminalized in the Mental Health Care Act of 2017 (33). Indian medical students also exhibit a strong aversion to physician-assisted suicide (32). In contrast, physician-assisted suicide has been legal for decades in Switzerland, and the psychiatrists surveyed in Switzerland supported the idea for patients with SPMI to some extent (23).
Third, while it might seem interesting to explore whether these differences in pro-life attitude relate to religious beliefs, Etzersdorfer and colleagues found no evidence that religion played a role in the differing attitudes to suicidal behavior of medical students from India and Austria (32). Referring primarily to the Hindu religion, they found no greater aversion to suicide than in the Christian religion and further noted that there is some evidence of institutionalized suicide in India. In a more recent questionnaire study, Thimmaiah and colleagues (34) reported that negative attitudes to suicidality are less common among Hindus than Muslims, and these cultural differences invite further research.
Besides the greater support for curation and suicide prevention, psychiatrists in India also assigned greater importance to the reduction of suffering and functionality in daily life than their counterparts in Switzerland. They agreed more strongly that palliative approaches might be indicated in patients with SPMI, even in the absence of life-limiting disease.
By implication, the participating psychiatrists in India tended to support both curative and palliative approaches for patients with SPMI. This suggests that, for psychiatrists in India, curative approaches and palliative psychiatry are not mutually exclusive but can complement each other to alleviate suffering and increase functionality in daily life in parallel to curative treatments (8). Such a notion of compatibility of palliative psychiatry and curative approaches may be facilitated by regarding the term palliative as not directly related to the end of life, which psychiatrists in India were significantly more likely to do than psychiatrists in Switzerland.
Strengths and limitations of the study
One limitation of the study is the low response rate of 6.7% in the Indian sample. Basing the calculation on the population who clicked on the link yields a response rate of 36.7%. The generalizability of the data may therefore be limited as the participants are likely to have an existing interest in SPMI and palliative care. However, there is evidence that nonresponse bias may be of less concern in physician surveys than in surveys of other populations (35). Also, response rates are known to be lower in online surveys (36) and in surveys of physicians (35), especially psychiatrists (37).
As only psychiatrists were surveyed, the generalizability of the response patterns to other professions is limited.
The observed differences between the two samples might relate to differences in age and career duration. It is also important to note that response behavior can vary across countries and cultures (38), which may be compounded by the fact that the questionnaires were presented in different languages (German and English). For example, the psychiatrists in India (up to 30%) chose the middle category more often than those in Switzerland. To limit and identify any interpretive bias associated with dichotomous significance testing, effect sizes were also calculated.
Other general limitations of this type of survey have already been mentioned in previous studies based on the same questionnaire (9, 23, 24) but can be briefly summarized as follows. First, a Likert scale can only reflect the opinions of individuals to a limited extent and cannot fully capture the complexity of the topic. Importantly, we did not assess how the individual participants conceptualize palliative psychiatry. Second, the case vignettes represent highly specific cases and are not representative of the respective disorders in general.
Implications for clinical practice and future research
The reluctance to integrate palliative psychiatry in existing mental healthcare structures may reflect the fact that it is too often associated with end of life, giving up, and hopelessness (2, 3, 7). The present findings, and especially the views of psychiatrists in India, suggest that first, palliative psychiatry is considered valuable across cultures as a means of improving patients’ quality of life, without necessarily accepting a reduction in life expectancy, and second, rather than asking “palliative or curative?”, we should discuss the possibility of palliative and curative, combining both approaches to offer optimal treatment to patients with SPMI. As Strand and colleagues (7) have argued, “[…] the type of interventions referred to as palliative are by no means ‘novel’ and ‘cutting-edge’—quite the contrary, we interpret palliative care as an approach defined by its goals and not by the use of specific treatments” (p. 6). It seems important, then, that researchers and clinicians focus on developing a framework for clinical practice that optimally combines curative and palliative approaches for the individual patient and situation.