EFFECTIVELY IMPLEMENTING PSYCHIATRIC ADVANCE DIRECTIVES TO PROMOTE SELF-DETERMINATION OF TREATMENT AMONG PEOPLE WITH MENTAL ILLNESS

Advance statements in mental healthcare: time to close the evidence to practice gap

This article discusses advance statements in mental health care, which allow individuals with mental disorders to express their preferences for treatment during mental health crises. Despite the evidence supporting their effectiveness, their implementation in clinical practice remains limited. This article explores variations among advance statements, such as psychiatric advance directives (PADs), joint crisis plans (JCPs) and self-binding directives (SBDs), highlighting their content, development process and legal status. We outline the benefits of advance statements, including empowerment, early intervention, improved therapeutic relationships and reduced compulsory admissions. We then draw attention to the challenges that may contribute to their lack of implementation, including legal complexities, communication issues, cultural factors, potential inequities, healthcare provider knowledge, changing preferences, resource constraints, crisis responses, data privacy, family involvement, and long-term evaluation. In conclusion, advance statements offer significant benefits but require addressing these critical aspects to ensure ethical and effective use. Bridging the evidence-to-practice gap is essential, with a focus on implementation science. Integrating these tools into routine clinical practice can significantly benefit individuals with severe mental disorders and mental health systems.

Advance Statements for Black African and Caribbean people (AdStAC): protocol for an implementation study

BACKGROUND

The UK government committed to legislating for Advance Choice Documents/Advance Statements (ACD/AS) following their recommendation by the Independent Review of the MHA (2018). ACDs/AS are yet to be implemented in routine practice despite evidence and high demand; they are associated with improved therapeutic relationships and a reduction (25%, RR 0.75, CI 0.61-0.93) in compulsory psychiatric admission. Barriers to their implementation are well documented, ranging from low knowledge levels to logistical challenges in accessing the content during episodes of acute care. In the UK this is an issue for Black people, who experience detention rates disproportionately (over three times) higher than those of White British people and have poorer care experiences and outcomes. ACDs/AS allow for Black people to have their concerns heard by mental health professionals in a care system where they often feel their views are ignored. AdStAC aims to improve Black service users' experiences in mental health services in South London by co-producing and testing an ACD/AS implementation resource with Black service users, mental health professionals and carers/supporters of Black service users.

METHODS/DESIGN

The study will take place in South London, England over three phases: 1) formative work through stakeholder workshops; 2) co-production of resources through a consensus development exercise and working groups; and 3) testing of the resources using quality improvement (QI) methods. A lived experience advisory group, staff advisory group and project steering committee will support the study throughout. The implementation resources will comprise: advance choice document/advance statement (ACD/AS) documentation, stakeholder trainings, a manual for mental health professionals to facilitate the processes of creating and revising advance statements, and informatics development.

DISCUSSION

The implementation resources will help increase the likelihood of the new mental health legislation in England being implemented effectively; through aligning evidence-based medicine, policy and law to effectively provide positive clinical, social and financial outcomes for Black people, the National Health Service (NHS) and wider society. This study will likely benefit a wider group of people with severe mental illness, as when marginalised groups who are least engaged, can be supported with these strategies, then the strategies are likely to work for others.

Psychiatric advance directives facilitated by peer workers among people with mental illness: economic evaluation of a randomized controlled trial (DAiP study)

AIMS

We aimed to assess the cost-effectiveness of psychiatric advance directives (PAD) facilitated by peer workers (PW-PAD) in the management of patients with mental disorders in France.

METHODS

In a prospective multicentre randomized controlled trial, we randomly assigned adults with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnosis of schizophrenia, bipolar I disorder or schizoaffective disorders, who were compulsorily hospitalized in the past 12 months, to either fill out a PAD form and meet a peer worker for facilitation or receive usual care. We assessed differences in societal costs in euros (€) and quality-adjusted life-years (QALYs) over a year-long follow-up to estimate the incremental cost-effectiveness ratio of the PW-PAD strategy. We conducted multiple sensitivity analyses to assess the robustness of our results.

RESULTS

Among the 394 randomized participants, 196 were assigned to the PW-PAD group and 198 to the control group. Psychiatric inpatient costs were lower in the PW-PAD group than the control group (relative risk, -0.22; 95% confidence interval, [-0.33 to -0.11]; P < 0.001), and 1-year cumulative savings were obtained for the PW-PAD group (mean difference, -€4,286 [-4,711 to -4,020]). Twelve months after PW-PAD implementation, we observed improved health utilities (difference, 0.040 [0.003-0.077]; P = 0.032). Three deaths occurred. QALYs were higher in the PW-PAD group (difference, 0.045 [0.040-0.046]). In all sensitivity analyses, taking into account sampling uncertainty and unit variable variation, PW-PAD was likely to remain a cost-effective use of resources.

CONCLUSION

PW-PAD was strictly dominant, that is, less expensive and more effective compared with usual care for people living with mental illness.

The Content of Psychiatric Advance Directives: A Systematic Review

OBJECTIVE

Psychiatric advance directives (PADs) enable users of mental health services to express their treatment preferences for future mental health crises. PAD completion rates remain low despite high rates of interest among service users and empirically confirmed benefits of their use. A systematic review of service users' preferences regarding the content of PADs could be a valuable resource for clinicians and policy makers and might help reduce barriers to PAD implementation.

METHODS

A systematic review concordant with PRISMA guidelines was conducted. CINAHL, Cochrane, EMBASE, PsycINFO, MEDLINE, PubMed, SCOPUS, and Web of Science databases were searched up to July 2, 2021. Included articles contained original empirical data on service users' preferences regarding the content of PADs or a document analysis of existing PADs. Studies were analyzed thematically, and a narrative synthesis was conducted. The Mixed Methods Appraisal Tool was used to assess the methodological quality and risk of bias of the included studies.

RESULTS

The search yielded 4,047 articles, 42 of which were eligible for inclusion. Six themes emerged (most of which included subthemes): signs of crisis, general treatment approach, preferences regarding the treatment setting, treatment preferences, coercion, and social instructions.

CONCLUSIONS

The concern that PADs may be unclear or incompatible with practice standards was not confirmed. Service users generally included clear, comprehensible, and clinically relevant information in their PADs, often providing underlying reasons for their preferences. These reasons were related to previous adverse effects of medication and personal experiences with hospital admissions.

Mental Health Service Users' Perspectives on Psychiatric Advance Directives: A Systematic Review

OBJECTIVE

Psychiatric advance directives (PADs) are documents that allow users of mental health services to express their preferences for treatment in future mental health crises. To increase the use of PADs in psychiatric practice, it is helpful to consider how service users view PADs and the factors that facilitate or hinder PAD creation and implementation. A systematic review of the empirical literature on this topic may help inform evidence-based policy making.

METHODS

A systematic review concordant with PRISMA guidelines was conducted. Relevant electronic databases were searched up to July 2, 2021. Articles containing original empirical data on service users' perspectives on PADs were included. Data were analyzed thematically, tabulated, and narratively synthesized.

RESULTS

Fifty-three articles were identified and included. The following categories were identified: general preferences regarding factors such as legal force and revocability; benefits of PADs at the personal, treatment-related, and social levels; challenges and barriers concerning PAD creation and application; and possible and experienced facilitators of PAD creation.

CONCLUSIONS

Users of mental health services are highly interested in PADs and regard them as tools to improve their involvement in care. They generally prefer legally binding PADs that can be revoked only when users are competent to consent. Barriers reported by service users were mainly related to the creation and application of PADs, and support in PAD creation was the most important facilitator identified. The involvement of mental health professionals in creating PADs appears essential to realize the benefits of PADs and to reduce barriers to their use.

Engaging in resuscitation status conversations in psychiatry: A qualitative study of nurses' perspectives

WHAT IS KNOWN ON THE SUBJECT?: Discussion and documentation of a patient's resuscitation status are essential aspects of any hospital admission, and yet, they seldomly occur in psychiatry. Nurses play an important role in resuscitation status determination by being an information broker, supporter and advocate. Persons with mental illness may be competent to engage in the determination of their resuscitation status and deserve the same respect and autonomy as other patients during this process. There are no published qualitative studies exploring healthcare providers experiences in initiating resuscitation status conversations in the psychiatric setting. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: An in-depth qualitative understanding of the complexity of resuscitation status determination in psychiatry. The shared experiences of nurses enacting their role in resuscitation status determination with patients admitted to psychiatry. The challenges of implementing a 'one-size fits all' approach to resuscitation status policies, and the ways in which depression and/or suicidal ideation influence the process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Role clarity and improved communication between providers about resuscitation status determination in psychiatry are needed. Hospital policies for resuscitation status determination must account for the psychiatric context to ensure patients' goals of care are known and upheld. Nurses working in psychiatry should initiate and more readily engage in resuscitation status conversations. ABSTRACT: Introduction Patients with mental illness experience stigma and marginalization, which affects the quality of their health care. In most settings, end-of-life decisions, including goals of care, must be discussed with all patients upon hospital admission, including determining cardiopulmonary resuscitation preferences in the event of a medical emergency. Despite this requirement, these conversations do not routinely occur in inpatient psychiatry. By default, patients become a 'full code status', mandating life-sustaining interventions. Aim To explore how and why resuscitation status conversations occur, or do not occur, in inpatient psychiatry from the perspectives of healthcare providers. Method Qualitative descriptive study using focus groups with nurses working in psychiatry. Results Nurses' experiences with initiating and engaging in resuscitation status conversations related to Working in Psychiatry, which represents the current practices and the participants' views of the nursing role; Caring for Psychiatric Patients, which describes how fluctuating competency and suicidality influence determination; and The Influence of Physical Health Status, which details how differences in physical health status affect how healthcare providers engage in resuscitation status determination. Discussion Although the importance of completing resuscitation status conversations with patients admitted to psychiatry was expressed by participants, they seldomly occur. There is ambiguity about when and how to determine patient wishes. Implications for practice Tailored strategies are needed to ensure patients' rights to self-determination are upheld when they are admitted to psychiatry. Nurses working in this setting would benefit from education, training and support to adequately initiate and engage in these conversations.

A Systematic Review of Shared Decision-Making Interventions for Service Users With Serious Mental Illnesses: State of the Science and Future Directions

OBJECTIVE

Shared decision making (SDM) is a health communication model that may be particularly appealing to service users with serious mental illnesses, who often want to be involved in making decisions about their mental health care. The purpose of this systematic review was to describe and evaluate participant, intervention, methodological, and outcome characteristics of SDM intervention studies conducted within this population.

METHODS

Systematic searches of the literature through April 2020 were conducted and supplemented by hand searching of reference lists of identified studies. A total of 53 independent studies of SDM interventions that were conducted with service users with serious mental illnesses and that included a quantitative or qualitative measure of the intervention were included in the review. Data were independently extracted by at least two authors.

RESULTS

Most studies were conducted with middle-age, male, White individuals from Western countries. Interventions fell into the following categories: decision support tools only, multicomponent interventions involving decision support tools, multicomponent interventions not involving decision support tools, and shared care planning and preference elicitation interventions. Most studies were randomized controlled trials with sufficient sample sizes. Outcomes assessed were diverse, spanning decision-making constructs, clinical and functional, treatment engagement or adherence, and other constructs.

CONCLUSIONS

Findings suggest important future directions for research, including the need to evaluate the impact of SDM in special populations (e.g., young adults and racial-ethnic minority groups); to expand interventions to a broader array of decisions, users, and contexts; and to establish consensus measures to assess intervention effectiveness.

Mental Health Professionals' Positions in Relation to Advance Statements: A Foucauldian Discourse Analysis

Advance Statements enable mental health patients to have their preferences considered in treatment decisions in the event of losing capacity, but their uptake is poor. This is for complex and often conflicting reasons and factors related to service user, clinician, and institutional priorities, which influence clinical practice. A Foucauldian discourse analysis approach was used to explore how 13 mental health clinicians positioned their role in relation to Advance Statements. Five positions emerged from the data: taking account of peoples' wishes, enabling people to have their say (to a point), we know what's best, firefighting with risk, and leverage and liability. Discursive practices demonstrated and reinforced power relations between patients, clinicians, and wider systems. These findings highlight the challenge of legitimizing the knowledge of patients and need for a cultural shift at a systems level, which recognizes the ways Advance Statements meet the needs of all stakeholders.

[Acceptance of Psychiatric and Somatic Advance Directives: A Comparison in Psychiatric Patients and Professionals]

OBJECTIVE

Assessment of the attitudes towards somatic and psychiatric advance directives in the German speaking part of Switzerland.

METHODS

Questionnaire for psychiatric patients, psychiatrists, psychologists, psychiatric nurses and peers assessing the attitudes towards three exemplary advance directives.

RESULTS

The attitudes were mainly positive in all participating groups. Compared to professionals (79-100 %), the somatic advance directive found approval in significantly less patients (46 %). There were no significant group differences regarding the psychiatric advance directives, but patients (58 % and 84 %) were slightly more agreeing compared to professionals (31-50 % and 62-70 %).

CONCLUSION

Psychiatric advance directives seem to be broadly accepted. The development of campaigns might help to raise the awareness about these instruments and increase their usage in clinical practice.

Psychiatric advance directives in Switzerland: Knowledge and attitudes in patients compared to professionals and usage in clinical practice

BACKGROUND

Psychiatric advance directives (PAD) were shown to be effective in the reduction of coercion and strengthening of the patients` autonomy. Therefore, the Swiss legislation was revised and stipulates that PAD must be taken into account during involuntary hospitalization. This study aimed to analyze knowledge on and attitudes towards this instrument in patients and healthcare practitioners and their usage in clinical practice.

METHODS

We developed a structured questionnaire and included patients (n = 110), psychiatrists (n = 205), psychologists (n = 85), nurses (n = 268) and peers (n = 16) to rate their knowledge on and attitudes towards PAD. We registered the existing PAD in patients and peers. The response rate varied between 17% (nurses), 19% (psychologists) 21% (psychiatrists), 33% (peers) and 56% (patients).

RESULTS

Only 7% of the participating patients had a PAD. Compared to the other groups, patients had the least knowledge on PAD. Psychiatrists were significantly more critical towards PAD. Concerns that PAD impede necessary and adequate treatment, restrict professionals and result in conflicts between patients and HCP were most frequently named as reason for critical attitudes.

CONCLUSIONS

Although being explicitly mentioned in the Swiss legislation the usage of PAD is small. Proactive information and training of psychiatrists might be helpful for a reduction of skeptical attitudes. This might improve the attitudes and lead to active support of patients during the preparation of PAD.

Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial - DAiP study

BACKGROUND

Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France.

METHODS

A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis.

SETTING

Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews.

PARTICIPANTS

400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French.

INTERVENTIONS

The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care.

MAIN OUTCOMES AND MEASURES

The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs.

DISCUSSION

Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

Advance statements in adult mental healthcare: an update

In this article we re-examine the conclusions of our article on advance statements in adult mental healthcare that was published in 2010 in the light of new literature published in the intervening decade. We explore the results of studies on the implementation and effectiveness of advance statements in adult mental health services, and then summarise recommendations for legislative changes from the Independent Review of the Mental Health Act 1983 that are relevant for England and Wales.

Patient-Centered Values and Experiences with Emergency Department and Mental Health Crisis Care

Little is known about what patients value in psychiatric crisis services or how they compare community-based services with those received in the emergency department. Three focus groups (n = 27) were held of participants who had received psychiatric crisis services in emergency departments or a community mental health center. Participants described care experiences and preferences. Focus groups were audio recorded, transcribed, and coded using a value-based lens. Themes included appreciation for feeling respected, basic comforts, and shared decision-making as foundations of quality care. Participants preferred the community mental health center. Research should address long-term outcomes to motivate change in psychiatric crisis care.

EAT-PAD: Educating about psychiatric advance directives in India

BACKGROUND

With India enacting the Mental Health Care Act (MHCA; No. 10 of 2017a), Psychiatric Advance Directives (PADs) have been legalised and have become binding orders for psychiatrists treating patients. There is a paucity of research into acceptability of PADs in Indian mental health care, likely due to a lack of awareness. There are no educational measures about PADs provided for in this Act. Facilitators and facilitation methods have not been elaborated upon as well.

AIM

The aim of this study is (a) to develop/evaluate the effectiveness of a structured Education-cum-Assessment Tool (EAT) in providing information regarding PADs and (b) to evaluate modes of facilitation required by patients to complete PADs.

METHODS

A tool was developed as per provisions regarding PADs in the Mental Health Care Bill of 2013. This tool was administered to patients ( n = 100), purposively sampled from the adult psychiatry review out-patient department (OPD). Patients were evaluated on retention of information, completion of PADs, modes of facilitation and time taken to write one.

RESULTS

Mean years of education was 8.28 (±5.74) years and mean duration of illness was 8.30 (±7.04) years. In all, 65% had Below-Poverty Line (BPL) status. All participants completed valid PADs in an average of 15 minutes. About 93% required facilitation via assistance in writing and reminding. The mean EAT scores implied above 70% retention but did not relate to types of facilitation.

CONCLUSIONS

EAT scores can be used as an approximate measure of the patient's ability to understand and retain information which is a part of decisional capacity. Types of facilitation can help in understanding patient's ability to communicate their choices. Service providers may find EAT a time-effective tool for uniformly educating service users regarding PADs and indirectly assessing competence.

Psychiatric Advance Directives Under the Convention on the Rights of Persons With Disabilities: Why Advance Instructions Should Be Able to Override Current Preferences

Psychiatric advance directives (PADs) are documents by means of which mental health service users can make known their preferences regarding treatment in a future mental health crisis. Many states with explicit legal provisions for PADs have ratified the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). While important UN bodies consider PADs a useful tool to promote the autonomy of service users, we show that an authoritative interpretation of the CRPD by the Committee on the Rights of Persons with Disabilities has the adverse consequence of rendering PADs ineffective in situations where they could be of most use to service users. Based on two clinical vignettes, we demonstrate that reasonable clinical recommendations can be derived from a more realistic and flexible CRPD model. Concerns remain about the accountability of support persons who give effect to PADs. A model that combines supported decision making with competence assessment is able to address these concerns.

What do service users want? A content analysis of what users may write in psychiatric advance directives in India

Although psychiatric advance directives give service users control over their care, very few studies exist on the content of PADs. This paper aims to contribute to this evidence base by presenting the content of psychiatric advance directives in India. Participants were 75 clients seeking outpatient care at a mental health services organisation in Tamil Nadu, India, who agreed to draft a PAD. Most clients were comfortable with appointing a representative (usually a family member) to make decisions on their behalf during a period of decisional incapacity or relapse, were willing to accept admission to the hospital/clinic and take medication if required, wanted to have a trusted person to discuss their mental health problems. No client used the opportunity to outright refuse treatment. This study highlights an important first step in improving the quality of mental health care by documenting user preferences for care in India. More in-depth research is needed to elicit rich descriptions of experiences of care and user-centred understanding of rights.

Users' and health professionals' values in relation to a psychiatric intervention: the case of psychiatric advance directives

Although clinical and organisational benefits have been expected from Psychiatric Advance Directives (PADs), their take-up rates remain low and their evaluation disappointing. The endorsement of PADs by stakeholders is decisive for their use and understanding stakeholders' preferences for implementation is crucial. A Multinomial Discrete Choice analysis was carried out of options for designing, completing, and honouring PADs, with a view to enhancing user autonomy, therapeutic alliance, care coordination, and feasibility. Although autonomy underlies the whole process, the criteria determining options varied with the stage of the intervention. These criteria should be taken into account in future PAD intervention and evaluation processes.

Psychiatric Advance Directives as a complex and multistage intervention: a realist systematic review

Psychiatric Advance Directives (PADs) are documents that allow users with severe and chronic mental illnesses to notify their treatment preferences for future crisis relapses and to appoint a surrogate decision-maker for a period of incompetence. Despite many supposed clinical and organisational benefits, their take-up rate has remained very low and their clinical evaluation has given contradictory results for organisational outcomes. Intermediary results are available, however, which rely on different theoretical views about how PADs are supposed to work. We carried out a realist systematic review that considered the PAD as a multistage intervention including the definition of the document, its completion and its access and honouring. We identified the theoretical frameworks underlying this kind of intervention and examined the available evidence that supported or contradicted the expectations at each stage of the intervention. Forty-seven references were retrieved, ranging from 1996 to 2009. Three frameworks underlie a PAD intervention: enhancement of the autonomy of the user, improvement of the therapeutic alliance and integration of care through partnership working. Although designed in the first place with a view to sustaining the user's autonomy, results indicate that the intervention is more efficient within a therapeutic alliance framework. Moreover, much is known about the completion process and the content of the document, but very little about its access and honouring. The mixture of expectations makes the purpose of PADs unclear, for example, crisis relapse prevention or management, advance planning of long-term or emergency care, or reduction in the resort to coercion. This may explain their low take-up rates. Hence, frameworks and purpose have to be clarified. The shape of the whole intervention at each stage relies on such clarification. More research is needed, particularly on the later stages of the intervention, as the evidence for how PADs should be implemented is still incomplete.

Medication preferences and adherence among individuals with severe mental illness and psychiatric advance directives

OBJECTIVE

Psychiatric advance directives allow patients with severe mental illness to document their preferences for particular medications. This study investigated the role of psychiatric advance directives in treatment choice and medication adherence.

METHODS

A total of 123 persons with severe mental illness recorded medication preferences in psychiatric advance directives. The authors compared medication preferences to prescribed medications over 12 months, determined concordance between preferred and prescribed medications, and examined the effect of concordance on medication adherence at 12 months.

RESULTS

Participants requested a median of two medications in their psychiatric advance directives (range from zero to six) and refused a median of one medication (range from zero to ten). Between baseline and follow-up there was a 27% increase in the number of medications prescribed that had been requested on the psychiatric advance directive (Wilcoxon matched pairs, p<.001). After correction for the number of medications listed in the psychiatric advance directive, a 10% increase in concordance remained significant (p<.001). Being prescribed at least one medication requested in the psychiatric advance directive predicted higher medication adherence at 12 months, after the analysis controlled for relevant covariates (odds ratio=7.8, 95% confidence interval=1.8-34.0).

CONCLUSIONS

Providing information about medication preferences in psychiatric advance directives may increase prescribing of patient-preferred medications even in noncrisis settings. Patients who were prescribed medications that they requested in advance were significantly more likely to adhere to medications, supporting the benefit of patient participation in medication choice. Psychiatric advance directives appear to be a clinically useful conduit for communicating patient medication preferences.

Medication preferences and adherence among individuals with severe mental illness and psychiatric advance directives

OBJECTIVE

Psychiatric advance directives allow patients with severe mental illness to document their preferences for particular medications. This study investigated the role of psychiatric advance directives in treatment choice and medication adherence.

METHODS

A total of 123 persons with severe mental illness recorded medication preferences in psychiatric advance directives. The authors compared medication preferences to prescribed medications over 12 months, determined concordance between preferred and prescribed medications, and examined the effect of concordance on medication adherence at 12 months.

RESULTS

Participants requested a median of two medications in their psychiatric advance directives (range from zero to six) and refused a median of one medication (range from zero to ten). Between baseline and follow-up there was a 27% increase in the number of medications prescribed that had been requested on the psychiatric advance directive (Wilcoxon matched pairs, p<.001). After correction for the number of medications listed in the psychiatric advance directive, a 10% increase in concordance remained significant (p<.001). Being prescribed at least one medication requested in the psychiatric advance directive predicted higher medication adherence at 12 months, after the analysis controlled for relevant covariates (odds ratio=7.8, 95% confidence interval=1.8-34.0).

CONCLUSIONS

Providing information about medication preferences in psychiatric advance directives may increase prescribing of patient-preferred medications even in noncrisis settings. Patients who were prescribed medications that they requested in advance were significantly more likely to adhere to medications, supporting the benefit of patient participation in medication choice. Psychiatric advance directives appear to be a clinically useful conduit for communicating patient medication preferences.

Psychiatric advance directives and social workers: an integrative review

Psychiatric advance directives (PADs) are legal documents that allow individuals to express their wishes for future psychiatric care and to authorize a legally appointed proxy to make decisions on their behalf during incapacitating crises. PADs are viewed as an alternative to the coercive interventions that sometimes accompany mental health crises for people with mental illness. Insofar as coercive interventions can abridge clients' autonomy and self-determination--values supported by the NASW Code of Ethics--social workers have a vested interest in finding ways to reduce coercion and increase autonomy and self-determination in their practice. However, PADs are also viewed as having the potential to positively affect a variety of other clinical outcomes, including, but not limited to, treatment engagement, treatment satisfaction, and working alliance. This article reviews the clinical and legal history of PADs and empirical evidence for their implementation and effectiveness. Despite what should be an inherent interest in PADs and the fact that laws authorizing PADs have proliferated in the past decade, there is little theoretical or empirical research on PADS in the social work literature.

Preferences for psychiatric advance directives among Latinos: views on advance care planning for mental health

OBJECTIVE

Psychiatric advance directives allow people to plan for future mental health care. Little is known about how minority groups, particularly Latinos, view these legal mechanisms. This study examined demand for, and attitudes toward, psychiatric advance directives among Latinos with mental illness (N=85), their family members (N=25), and their clinicians (N=30).

METHODS

All participants were interviewed.

RESULTS

Participants showed substantial interest in completing psychiatric advance directives, specifically involving family or other surrogates in the preparation and execution. There were few between-group differences in attitudes toward directives.

CONCLUSIONS

Psychiatric advance directives provide an acceptable way to increase culturally appropriate services and family involvement for Latinos with mental illness. Psychiatric advance directive interventions should capitalize on the centrality of the family in Latino culture, which could provide an opportunity to reduce mental health crises in this population.

Preferences for psychiatric advance directives among Latinos: views on advance care planning for mental health

OBJECTIVE

Psychiatric advance directives allow people to plan for future mental health care. Little is known about how minority groups, particularly Latinos, view these legal mechanisms. This study examined demand for, and attitudes toward, psychiatric advance directives among Latinos with mental illness (N=85), their family members (N=25), and their clinicians (N=30).

METHODS

All participants were interviewed.

RESULTS

Participants showed substantial interest in completing psychiatric advance directives, specifically involving family or other surrogates in the preparation and execution. There were few between-group differences in attitudes toward directives.

CONCLUSIONS

Psychiatric advance directives provide an acceptable way to increase culturally appropriate services and family involvement for Latinos with mental illness. Psychiatric advance directive interventions should capitalize on the centrality of the family in Latino culture, which could provide an opportunity to reduce mental health crises in this population.