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 deescalating 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.