Objective-Studies show a high potential demand for psychiatric advance directives but low completion rates. The authors conducted a randomized study of a structured, manualized intervention to facilitate completion of psychiatric advance directives.Method-A total of 469 patients with severe mental illness were randomly assigned to a facilitated psychiatric advance directive session or a control group that received written information about psychiatric advance directives and referral to resources in the public mental health system. Completion of an advance directive, its structure and content, and its short-term effects on working alliance and treatment satisfaction were recorded.Results-Sixty-one percent of participants in the facilitated session completed an advance directive or authorized a proxy decision maker, compared with only 3% of control group participants. Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the advance directive to refuse some medications and to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment. At 1-month follow-up, participants in the facilitated session had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the mental health services they believed they needed.Conclusions-The facilitation session is an effective method of helping patients complete psychiatric advance directives and ensuring that the documents contain useful information about patients' treatment preferences. Achieving the promise of psychiatric advance directives may require system-level policies to embed facilitation of these instruments in usual-care care settings.A psychiatric advance directive is a legal document that allows a patient to consent to or refuse future mental health treatment in the event of an incapacitating psychiatric crisis by documenting advance instructions or appointing a surrogate decision maker (1). Laws on psychiatric advance directives were intended to support patients' self-determination at times when they are particularly vulnerable to loss of autonomy, to help them ensure that their preferences are known, and to minimize unwanted or involuntary treatment (2, 3). Advocates for psychiatric advance directives hope that the very process of preparing these documents will enhance patients' sense of trust and collaboration with providers, thereby improving the therapeutic alliance and engagement with treatment (4, 5).Address correspondence and reprint requests to Dr. Swanson, Box 3071, Duke University Medical Center, Durham, NC 27710; jeffrey.swanson@duke.edu.. NIH Public Access Author ManuscriptAm J Psychiatry. Author manuscript; available in PMC 2013 August 20.Published in final edited form as: Am J Psychiatry. 2006 November ; 163(11): 1943-1951. doi:10.1176/appi.ajp.163.11.1943 NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptStructu...

This study revealed several modifiable barriers to healthy eating. Interventions that addressed these could aid in improving the diet and lowering the risk of cardiovascular disease in this population. Recommendations are to provide healthy eating education that is individualized, emphasizes the health consequences of poor eating, and provides opportunities to prepare and taste healthy foods. Family and friends should be included in all educational efforts. At community mental health centers and group homes, only healthy foods should be offered. Lastly, practitioners should encourage eating a healthy diet, inquire about eating in response to emotions, and explore the impact of psychiatric medications on eating behaviors.

The encouraging results of this pilot study indicate that electronic decision supports may facilitate motivation to quit smoking and use of cessation treatment among people with severe mental illnesses.

Clinicians should incorporate physical health goals as a part of treatment planning. Agencies also can play a role in increasing exercise through the implementation of programs.

The website usability recommendations provide some guidelines for interventionists developing web tools for people who experience serious psychiatric disabilities. In general, insights from the study highlight the need for thoughtful design and usability testing when creating a website for people with severe mental illness.