Mental Health Service Users? Perspectives on Psychiatric Advance Directives: A Systematic Review

Objective: Psychiatric advance directives (PADs) are docu-ments that allow users of mental health services to express their preferences for treatment in future mental health cri-ses. To increase the use of PADs in psychiatric practice, it is helpful to consider how service users view PADs and the factors that facilitate or hinder PAD creation and imple-mentation. A systematic review of the empirical literature on this topic may help inform evidence-based policy making.Methods: A systematic review concordant with PRISMA guidelines was conducted. Relevant electronic databases were searched up to July 2, 2021. Articles containing original empirical data on service users' perspectives on PADs were included. Data were analyzed thematically, tabulated, and narratively synthesized.Results: Fifty-three articles were identified and included. The following categories were identified: general preferences regarding factors such as legal force and revocability; benefits of PADs at the personal, treatment-related, and social levels; challenges and barriers concerning PAD creation and appli-cation; and possible and experienced facilitators of PAD creation.Conclusions: Users of mental health services are highly in-terested in PADs and regard them as tools to improve their involvement in care. They generally prefer legally binding PADs that can be revoked only when users are competent to consent. Barriers reported by service users were mainly re-lated to the creation and application of PADs, and support in PAD creation was the most important facilitator identified. The involvement of mental health professionals in creating PADs appears essential to realize the benefits of PADs and to reduce barriers to their use.

Automated summary

Psychiatric advance directives (PADs) are highly valued by users of mental health services as tools to improve their involvement in care. Users generally prefer legally binding PADs that can only be revoked when they are competent to consent. Barriers to PAD creation and application were mainly related to the process itself, while support in PAD creation was identified as the most important facilitator. The involvement of mental health professionals is essential to realize the benefits of PADs and reduce barriers to their use.