How do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study From India

Abstract

Background: Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce. Aims: To determine the possible treatment options our clients make as a part of psychiatric advance directives. Materials and Methods: Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices. Results: About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future. Conclusion: The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.

Advance healthcare directives in mental health: A qualitative analysis from a Spanish healthcare professional's viewpoint

“…Although the only systematic review carried out using AHD in mental health does not establish specific recommendations derived from insufficient evidence in this regard (Campbell & Kisely, ), in the last decade, seemingly promising benefits of AHDs as a recovery tool have been described by international studies. The main benefits identified are as follows: improved adherence to prescribed medication, reduced crisis symptom severity and coercive interventions, greater satisfaction regarding treatment, earlier recovery and improved therapeutic relationships with mental healthcare professionals (Easter, Swanson, Robertson, Moser, & Swartz, ; Tekkalaki et al, ). Additionally, the prevention of the risk of self‐harm and violence towards others is pointed out, as well as a reduction in nights in prison and contacts with the judicial system (Suess Schwend et al, ).…”

Advance statements in adult mental healthcare: an update

“…Recent changes in mental health legislation in different parts of the world have sparked an interest in advance statements, and a number of articles have been published describing implementation challenges and early results from evaluations of adopting advance directives into routine care. In India, psychiatric advance directives have been incorporated into the Mental Health Care Act 2017 (Ratnam 2015) and a number of studies explored different aspects of this process (Sarin 2012; Kumar 2013; Shields 2013; Pathare 2015; Inamdar 2016; Gowda 2018; Tekkalaki 2018). In Australia, psychiatric advance directives have now been incorporated into four jurisdictions (Ouliaris 2017), and the Commonwealth of Virginia, USA, has undertaken efforts to incorporate the completion of psychiatric advance directives into routine mental health services for individuals with severe mental illness (Wilder 2013; Kemp 2015, Zelle 2015).…”

Advance directives and nominated representatives: A critique

“…In another study[ 14 ] in Karnataka, 50 patients were interviewed in a private medical college. Of them, the majority insisted on retaining their current treatments and wanted to know more about PADs.…”

“…When introducing legally binding directives, it is an apprehension among clinicians that it would be used to withdraw consent for all the future treatments. However, this apprehension is unfounded, as studies even in India report no outpatients refusing consent for future treatment,[ 10 14 ] but in one study from NIMHANS, 4 out of 174 inpatients did not want any future treatment for mental illness. [ 13 ] PADs stating refusal of all treatments could be specifically identified before registration and can be examined on a case by case basis.…”