Consistency of psychiatric crisis care with advance directive instructions.

OBJECTIVES: Psychiatric advance directives document clients' treatment preferences in advance of periods of diminished capacity for decision making. This article presents the first empirical data regarding rates and predictors of whether crisis care is consistent with psychiatric advance directives. METHODS: Participants were 106 community mental health outpatients who had completed a directive. Participants' mental health services were examined over a two-year period with interviews and chart reviews to determine whether clinical interventions were consistent with directive instructions. RESULTS: Across 90 crisis events in which an advance directive was accessed, the average rate of care consistent with directive instructions was 67%. Instructions regarding medications, preemergency interventions, nonhospital alternatives, and most nontreatment personal care issues were consistent with care in nearly all cases. Somewhat less consistent with care were instructions to contact a surrogate decision maker and preferences among hospitals; between hospitals and hospital alternatives; and among seclusion, restraint, and sedating medication. Clients with fewer prior outpatient commitment orders and who had a surrogate decision maker who accessed the directive were more likely to have care consistent with directive instructions. The most commonly reported reason for overriding directive instructions was clinical need. CONCLUSIONS: Overall, crisis care was largely consistent with directive instructions. To increase the likelihood of consistency, clients would be well advised to appoint a surrogate decision maker, particularly one who could be actively involved during crises. Encouraging creation and use of directives could be viewed as a positive step in the process of recovery and as an additional method of communicating client preferences during psychiatric crises.

Competency for creation, use, and revocation of psychiatric advance directives.

Psychiatric advance directives help promote patient involvement in treatment and expedite psychiatric care. However, clinicians are unsure of how to use directives, partly due to poor clarity regarding standards for capacity to create, use, and revoke them. This article recommends possible capacity standards. Capacity to create directives is a legal presumption, supported by empirical data. Standards are discussed for the subset of cases in which capacity assessment is needed. Use of directives may be triggered by incapacity to provide informed consent to treatment, although tailored, individualized points of activation may also be considered. In many states, revocation of a psychiatric advance directive requires adequate decision-making capacity. Setting a capacity standard for revocation presents challenges, however, in light of obstacles to providing treatment when revocation is attempted and the fact that many patients prefer revocable directives. As more directives are created and used, additional research and statutory refinements are warranted.

The content and clinical utility of psychiatric advance directives.

OBJECTIVE: This paper provides the first systematic examination of the content and clinical utility of psychiatric advance directives, which are documents that specify treatment preferences in advance of periods of compromised decision making. METHODS: Directives were completed by 106 community mental health center outpatients with at least two psychiatric hospitalizations or emergency department visits within two years. Participants used AD-Maker software in groups of up to six people led by peer trainers. Clinical utility was defined as the degree to which instructions are clinically feasible, useful, and consistent with standards of care. RESULTS: Fifty-five percent of participants were female, and 24 percent were nonwhite. Their mean+/-SD age was 42+/-9.1 years. Primary diagnoses included schizophrenia spectrum disorders (44 percent), bipolar disorders (27 percent), major depression (22 percent), and other disorders (7 percent). Eighty-one percent of participants listed preferred medications, most often antidepressants and second-generation antipsychotics, and 64 percent listed medications they would refuse, most commonly first-generation antipsychotics. Sixty-eight percent preferred hospital alternatives over hospitalization, 89 percent specified methods of de-escalating crises, and 72 percent indicated that they would refuse electroconvulsive therapy (ECT). Forty-six percent appointed a surrogate decision maker. Fifty-seven percent desired a directive that is irrevocable during periods of incapacity. Instructions were rated as feasible, useful, and consistent with practice standards for at least 95 percent of the advance directives, with the exception of instructions about the willingness to use medications not specifically listed in the directive. CONCLUSIONS: Results suggested that psychiatric advance directives provide a wealth of treatment preference information that is almost uniformly considered clinically useful. Although the utility of advance directives may vary depending on the circumstances of specific crisis episodes, the information provided can expedite and strengthen clinical care.

Geriatric patients improve as much as younger patients from hospitalization on general psychiatric units.

OBJECTIVES: To determine whether geriatric patients aged 65 and older on general adult psychiatric units improve as much as younger patients, over what duration their improvement occurs, and their risk of readmission. DESIGN: Cohort study. SETTING: Inpatient psychiatric unit of an urban, university-affiliated, county hospital from January 1993 through August 1999. PARTICIPANTS: A total of 5,929 inpatients. MEASUREMENTS: Standardized, routine assessments by attending psychiatrists included the Psychiatric Symptom Assessment Scale (PSAS) on admission and discharge. Discharge scores, length of stay (LOS), and risk of readmission within 1 year were modeled for the groups using multiple regression analyses. RESULTS: Geriatric patients constituted 5% (n=299) of the 5,929 admissions. In multivariate analysis, geriatric status was not associated with discharge PSAS scores. Median LOS was longer for geriatric patients (16 days) than younger patients (10 days, P<.001), especially in older women (14 days) and geriatric patients with mild medical illness severity (13 days vs 11 days in those with moderate-to-severe medical illness). Geriatric patients were as likely to be readmitted within 1 year of discharge as younger patients. CONCLUSION: Geriatric patients on general inpatient psychiatry units improved as much as younger patients. Their longer LOS was associated with milder medical illness severity. There may be a role for more specialized care of elderly women or geriatric patients with mild to moderate medical illness to improve the efficiency of their care.

Interest in psychiatric advance directives among high users of crisis services and hospitalization.

OBJECTIVES: This study examined rates of interest in creating psychiatric advance directives among individuals at risk of psychiatric crises in which these directives might be used and variables associated with interest in the directives. METHODS: The participants were 303 adults with serious and persistent mental illnesses who were receiving community mental health services and who had experienced at least two psychiatric crises in the previous two years. Case managers introduced the concepts of the directives and assessed participants' interest. The associations between interest in the directives and demographic characteristics, psychiatric symptoms, level of functioning, diagnosis, history of hospitalizations, history of outpatient commitment orders, support for the directives by case managers, and site differences were examined. RESULTS: Interest in creating a directive was expressed by 161 participants (53 percent). Variables significantly associated with interest were support for the directives by a participant's case manager and having no outpatient commitment orders in the previous two years. Reasons for interest included using the directives in anticipation of additional crises and as a vehicle to help ensure provision of preferred treatment. CONCLUSIONS: Substantial interest in psychiatric advance directives was shown among individuals with serious and persistent mental illness. The results strongly suggested that attitudes of clinicians about psychiatric advance directives are associated with interest in the directives among these individuals. Therefore, it is important to educate clinicians and address their concerns about the directives so that they can more comfortably support creating the documents. A shift in values may also be necessary to more consistently recognize and honor patients' treatment preferences as specified in the directives.

Psychometric properties and utility of the problem severity summary for adults with serious mental illness.

OBJECTIVE: The authors studied the psychometric properties and utility of the Problem Severity Summary (PSS), a 13-item instrument that assesses symptom severity and functioning among adults with severe and persistent mental illness. METHODS: Case managers rated the PSS among more than 1,000 adults with severe and persistent mental illness who were receiving services at either mainstream community mental health centers or specialty community mental health centers (serving various minority groups) in one county in Washington State. A subsample of clients was used to assess the concurrent validity of the PSS with the Psychiatric Symptom Assessment Scale. RESULTS: Interrater reliability was adequate for ten of the 13 PSS items. Four meaningful factors were derived, each with adequate internal consistency: community functioning, negative social behavior, affective distress, and psychotic disturbance. The PSS demonstrated adequate concurrent and predictive validity. Sensitivity of the PSS factors to change showed that scores on three of the four scales changed significantly over one year. Discriminant validity indicated that the PSS is generally unbiased in terms of demographic characteristics. CONCLUSIONS: The PSS is a brief, easily administered instrument that shows psychometric promise for use in clinical contexts, such as treatment planning, concurrent review of care, and guidance for level-of-care decisions, as well as for quality management purposes.

Barriers to metabolic care for adults with serious mental illness: provider perspectives.

This study assessed barriers to metabolic care for persons with serious mental illness (SMI) by surveying experienced healthcare providers. Sixty-eight medical, mental health, and other stakeholders who care for patients with SMI attended a CME conference focused on medical management of SMI patients in 2007. They completed a 27-item survey assessing barriers to and systemic responsibility for metabolic care. The top three ranked barriers were: "separate mental health and primary care systems," "patient's lack of resources," and "[mental health] providers are not trained to do basic primary care." Results indicated that ratings of CMHC responsibility for SMI metabolic care (M = 5.2, SD = 1.5) were significantly lower than ratings of public health (M = 5.7, SD = 1.4), t(66) = 2.3, p = 0.027, and primary care providers (M = 6.3, SD = 1.1), t(67) = 4.7,p <0.001. Experienced providers identified a lack of integrated care and patient characteristics as important barriers to metabolic care and concluded that the primary care and public health systems are primarily responsible for metabolic treatment.

Initial findings from Parent Party Patrol: an intervention to reduce adolescent substance use through reduced involvement in unchaperoned parties.

This article presents preliminary evaluation findings from Parent Party Patrol (PPP). PPP is a two-hour single-session intervention that provides information to parents about ways to increase monitoring and improve communication and family guidelines regarding substance use, with the goal of reducing adolescent involvement in unsupervised activities and associated substance use. Seventy-three attendees from 15 PPP sessions completed baseline and three- to six-month follow-up information. At follow-up, participants showed significantly increased awareness of adolescent substance use and unchaperoned activities, improved communication and use of family guidelines regarding substance use, and increased monitoring of their children's activities. A significant reduction in adolescent attendance at unchaperoned parties was also reported. Replication of the study with a larger, more representative sample and controlled design is suggested. As adolescent substance use is a multidetermined problem, PPP may be best viewed as one part of a broader comprehensive substance abuse prevention program.

Unlinking disability income, substance use and adverse outcomes in dually diagnosed, severely mentally ill outpatients.

The goals of the current study were to determine whether incorporating disability benefit management into combined outpatient psychiatric/addiction treatment was feasible and clinically useful for managing severely mentally ill, substance-abusing patients over time, and then if patients in this program would demonstrate the first-week-of-the-month increased substance abuse and hospitalizations shown in other studies. Forty-four patients were studied for an average of forty weeks, with little treatment or study dropout. There was no evidence in either the schizophrenic/cocaine abuser or the broader diagnostic sample of the cyclic first-of-the-month pattern of substance use and hospitalizations observed in other studies. Findings suggest that combined treatment/benefit management programs are clinically feasible and effective in stabilizing patients and keeping them in treatment.