Psych News Alert: Patients Provide Clear Preferences in Psychiatric Advance Directives, Review Finds

When patients complete psychiatric advance directives (PADs), they tend to document clear and comprehensive mental health treatment preferences, according to a report published this week in Psychiatric Services. Patients using these advanced directives also rarely use the documents to refuse all psychiatric medications in advance, the authors of the review found.

PADs are documents that enable patients to express their treatment preferences ahead of potential mental health crises. While studies show that the use of PADs can promote patient well-being, prevent harm, and improve the patient-physician relationship, the use of these advanced directives has progressed slowly, wrote Anne-Sophie Gaillard, B.A., and Esther Braun, M.D., M.A., of the Institute for Medical Ethics and History of Medicine at Ruhr University Bochum in Germany and colleagues.

To better understand the information that patients include in PADs, Gaillard, Braun, and colleagues conducted a systematic literature review of articles about PADs that appeared in CINAHL, Cochrane, EMBASE, PsycINFO, MEDLINE, PubMed, SCOPUS, and Web of Science databases. Articles were excluded if they included only patients with dementia, patients with mild cognitive impairment, or older adults without mental disorder, or if they only contained data on advance directives related to end-of-life decision making.

The authors identified 42 articles eligible for inclusion, including 4,633 participants aged 18 or older. The articles were published between 1999 and 2021 and conducted in 11 countries, primarily in the United Kingdom, the United States, New Zealand, and India. PADs were mostly created for people with diagnoses of schizophrenia, bipolar disorder, depression, or a serious mental illness in general. The authors categorized the content of the PADs into six themes, including the following:

• Signs of crisis: In half of the articles, patients’ PADs included early warning signs (such as negative thoughts or aggressive behaviors), crisis symptoms (such as suicidal thoughts), and triggers (such as seeing friends and family whom the patients did not wish to see) that may precede a mental health crisis.
• General treatment approach: In 21% of the articles, patients’ PADs emphasized the importance of being met with understanding, empathy, and positivity by professionals.
• Treatment setting preferences: In 71% of the articles, PADs included patients’ preferences on treatment settings, often recognizing the need for hospitalization if necessary, such as if they start hearing voices, but usually expressing their preference to be treated at home or for community alternatives to hospital treatment.
• Treatment preferences: In 90% of the articles, PADs expressed patients’ preferences concerning medications or electroconvulsive therapy (ECT), often providing reasons for these preferences, such as concerns that the medications would worsen their illnesses.
• Coercion: In half of the articles, PADs included information on de-escalation and coping strategies to prevent or reduce the use of coercive measures. They also often included preferences regarding those coercive measures should they prove necessary (for example, some agreed to specific coercive measures in advance but limited them to certain situations).
• Social instructions: In 69% of the articles, patients’ PADs indicated who should be contacted in the event of a crisis and requested social support in the form of family involvement, support groups, or spiritual support.

The authors noted that patients’ completion of most of the PADs were facilitated by mental health professionals and concluded that, “[f]acilitation during the drafting process may decrease the likelihood of ethical dilemmas during future crisis situations.”

The authors concluded, “The findings from this review may serve as the basis for the development of PAD templates and manuals for the facilitation process.”

For related information, see the Psychiatric Services article “Help and Hindrances to Completion of Psychiatric Advance Directives” and the Psychiatric News article “Mobile App Helps People With SMI Create Crisis Plan.”

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