Facilitated Psychiatric Advance Directives: A Randomized Trial of an Intervention to Foster Advance Treatment Planning Among Persons with Severe Mental Illness

Abstract

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...

A Typology of Community Violence Perpetration and Victimization Among Adults With Mental Illnesses

“…Although most studies find co-occurring substance use disorder increases risk for violence perpetration (Swanson et al, 1990; Swanson et al, 2006; Van Dorn et al, 2012) and victimization (Goodman et al, 2001) in adults with mental illnesses, a primary diagnosis of substance use disorder was not associated with perpetration only or victimization only. It did, however, increase likelihood of membership in the victim–perpetrator group.…”

“…These results may reflect an overall increase in adverse outcomes in adults with a primary diagnosis of substance use disorder. Indeed, substance use is widely recognized as a risk factor for adverse outcomes among adults with mental illnesses (Swanson et al, 2006; Van Dorn et al, 2012). …”

“…That said, compared with the general population, the sex difference may be smaller or reversed for adults with mental illnesses (Hiday, Swartz, Swanson, Borum, & Wagner, 1998; Lidz, Mulvey, & Gardner, 1993; Short, Thomas, Mullen, & Ogloff, 2013; Stueve & Link, 1998). Findings also may reflect increased opportunity: Women with mental illnesses are more likely to live with family members and men to live alone (Swanson et al, 2006). Indeed, in another analysis of the present data (Desmarais et al, 2014), the majority of violent incidents were perpetrated in residential settings.…”

“…Future research should incorporate additional factors, such as socioeconomic status, social support, and access to treatment. Third, with our focus on primary diagnoses, we did not include any indication of co-occurring substance use disorders, which are known to heighten risk for both violence perpetration and victimization (e.g., Swanson et al, 2006; Van Dorn et al, 2012). Further exploration of these factors, as well as co-occurring disorders, may add to our understanding the overlap between perpetration and victimization in adults with mental illnesses.…”

“…Baseline data were pooled from five studies of adults with mental illnesses: (a) Facilitated Psychiatric Advance Directive (F-PAD) Study ( n = 469; Swanson et al, 2006); (b) MacArthur Mental Disorder and Violence Risk (MacRisk) Study ( n = 1,136; Steadman et al, 1998); (c) Schizophrenia Care and Assessment Program (SCAP) Study ( n = 404; Swanson, Swartz, & Elbogen, 2004); (d) MacArthur Mandated Community Treatment (MacMandate) Study ( n = 1,011; Monahan et al, 2005); and (e) Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study ( n = 1,460; Lieberman et al, 2005). A total of 4,474 adults with mental illnesses are included in the present analyses.…”