Interest in psychiatric advance directives among high users of crisis services and hospitalization

Objectives: This study examined rates of interest in creating psychiatric advance directives among individuals at risk of psychiatric crises in which these directives might be used and variables associated with interest in the directives. Methods: The participants were 303 adults with serious and persistent mental illnesses who were receiving community mental health services and who had experienced at least two psychiatric crises in the previous two years. Case managers introduced the concepts of the directives and assessed participants' interest. The associations between interest in the directives and demographic characteristics, psychiatric symptoms, level of functioning, diagnosis, history of hospitalizations, history of outpatient commitment orders, support for the directives by case managers, and site differences were examined. Results: Interest in creating a directive was expressed by 161 participants (53 percent). Variables significantly associated with interest were support for the directives by a participant's case manager and having no outpatient commitment orders in the previous two years. Reasons for interest included using the directives in anticipation of additional crises and as a vehicle to help ensure provision of preferred treatment. Conclusions: Substantial interest in psychiatric advance directives was shown among individuals with serious and persistent mental illness. The results strongly suggested that attitudes of clinicians about psychiatric advance directives are associated with interest in the directives among these individuals. Therefore, it is important to educate clinicians and address their concerns about the directives so that they can more comfortably support creating the documents. A shift in values may also be necessary to more consistently recognize and honor patients' treatment preferences as specified in the directives.