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.

Support needed to create psychiatric advance directives.

Psychiatric advance directives (PADs) inform treatment during periods of compromised decision-making. We report consumer desire and need for support to create PADs among 106 adult outpatients with severe and persistent mental illness. PADs were completed using computer software and flexible peer support. All participants were able to complete PADs. However, nearly all participants needed support using the software, or clarification of PAD information. Types of support needed may vary depending on PAD creation methods. While one-third of participants wanted support from case managers to complete PADs, the appropriate level of clinician support is not clear-cut, and should be at consumers' discretion.

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.