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Palliative psychopharmacology: a putative specialty to optimize the subjective quality of life.

Mainstream medicine is concerned with the diagnosis and management of disease. Control of symptoms is important, but subordinated to control of disease. However, when a disease is judged to be incurable or ‘terminal’, it may be better to manage the patient palliatively. The difference is that palliative medicine uses the medical armamentarium to optimize quality of life rather than maximize the chances of curing or preventing disease.

Mainstream psychiatry aims to cure, control or prevent psychological disease. To this end, it deploys an armamentarium of psychopharmacological agents (and psychological therapies). But if life itself is regarded as a terminal disease, and one that is for some people characterized by chronic and severe psychological symptoms, then there is a role for a palliative speciality that deploys the psychiatric armamentarium to optimize the subjective quality of life. In short, a speciality which aims to make people feel better. Such a speciality could be named palliative psychopharmacology (PP).

The difference between palliative medicine and palliative psychopharmacology is that while the first is a thriving medical speciality, the second is just an idea. The purpose of this essay is to argue that PP, or its functional equivalent, ought to exist.

It might be argued that the speciality of psychiatry already does the job of palliative psychopharmacology. However, mainstream psychiatry has several features which render it unsuited to practising a palliative function.

The most important reason is its public health role. Psychiatry is historically a speciality concerned with safety—the prime directive is to protect the public from mad people (and secondarily to protect mad people from the public and from themselves). Asylums were places of separation, of the insane from their family and communities. They may sometimes have been of therapeutic benefit, and may perhaps have made patients feel better, but even if they made …