Evaluating Ineffective Treatments: A Proposed Model for Discussing Futility in Psychiatric Illness

Background Treatment futility and terminality discussions arise rarely in psychiatric practice, frequently instilling apprehension, as there is little written that defines these terms in relation to mental illness. It therefore remains uncertain how to deal with cases that are refractory to multimodal interventions and that demonstrate limited improvement or even a worsening trajectory. Any viable solution needs to respect patient autonomy and maintain both beneficence and nonmaleficence, while taking into account the strained resources of the mental health care system as a whole. Objective This article reviews historical conflicts surrounding the notion of futility in psychiatric disorders, and proposes and elaborates a set of six criteria that psychiatrists can use in working through these difficult cases. Given the potential controversy involving futility in psychiatry, it proves helpful to understand its similarity to the notion of futility in standard medical contexts. This article also works through some of the common concerns or objections regarding the application of futility in psychiatric contexts. Conclusions Futility in psychiatric illness is a concept that the psychiatric community needs to understand and address, given the limited treatment options available to our field, as well as the limitations of health care resources. The proposed framework allows for ethically appropriate treatment decisions for treatment-resistant patients-respecting their individual wishes while ensuring appropriate care.