Psychiatric Advance Directives: A Review of the Evidence

Short abstract

Psychiatric advance directives (PADs) allow individuals with psychiatric conditions to document their preferences for treatment and interactions during a mental health crisis before that crisis occurs. This environmental scan combines evidence from systematic reviews, primary empirical literature, and grey literature to better understand the state of the evidence regarding implementing PADs in community, inpatient, and outpatient contexts.

Abstract

Psychiatric advance directives (PADs) offer individuals with psychiatric conditions the opportunity to document their preferences for treatment and interactions during a mental health crisis before that crisis occurs. In completing a PAD, individuals are encouraged to identify and document their preferences for medication management, setting of care, points of contact, a decisionmaking surrogate, and ways of interacting with emergency response and health care teams. Although PADs have grown in popularity and their legality has been increasingly recognized in international contexts and among individual U.S. states, evidence regarding their use is not well synthesized or documented. In this environmental scan, the authors take a broad approach that combines evidence from systematic reviews, primary empirical literature, and grey literature to better understand the state of the evidence regarding implementing PADs in community, inpatient, and outpatient contexts.

The authors sought to identify the potential and realized benefits of PADs, the barriers to the adoption and implementation of PADs, and promising practices for PAD implementation. This study summarizes those findings and can help inform future efforts to develop and implement PADs. Overall, PADs are a promising tool to improve care for individuals with serious mental illness; however, implementation requires clear legal guidance and clinician buy-in to ensure the effectiveness of PADs.

Psychiatric advance directives (PADs) offer individuals with psychiatric conditions the opportunity to document their preferences for treatment and interactions during a mental health crisis before that crisis occurs. PADs are typically promoted for persons with serious mental illness (SMI)—that is, a mental, behavioral, or emotional disorder resulting in a functional impairment that substantially interferes with or limits major life activities (National Institute of Mental Health, 2024). However, anyone with a history of mental illness, regardless of severity, may benefit from this type of advance planning. In completing a PAD, individuals are encouraged to identify and document their preferences for medication management, setting of care, points of contact, a decisionmaking surrogate, and ways of interacting with emergency response and health care teams (Braun et al., 2023; Gaillard et al., 2023). For example, individuals could indicate a preferred hospital or mental health provider. They also may request a hospitalization alternative (e.g., outpatient care) or specific medication (or no medication to be used), or they may express preferences with regard to electroconvulsive therapy or psychotherapy (Gaillard et al., 2023). A PAD template recently developed and tested in seven California counties also addressed such concepts as preferred deescalation techniques (e.g., music), potential triggers that might exacerbate a crisis, reproductive health care needs, and other aspects of crisis response and treatment for situations in which an individual might not be able to communicate their preferences or psychiatric history (see Siconolfi et al., 2025; Psychiatric Advance Directive, undated). Mental health researchers and professionals have suggested that documenting these preferences can facilitate respect for the autonomy, preferences, and values of an individual who may lose the capacity to make or communicate their decisions during a mental health crisis (Francis, Hazelton, and Wilson, 2024).

Individuals can complete a PAD independently or receive informal and formal support from others during the process (e.g., facilitation by a peer worker, social worker, lawyer, family member, or friend). A PAD that is facilitated by a mental health professional as part of an individual's mental health treatment is often called a joint crisis plan (JCP) (Gaillard et al., 2023). A self-binding directive (SBD), or Ulysses agreement, is a narrower, more directive version of a PAD that contains an agreement that one's preferences voiced during crisis should be overridden in favor of longer-term agreed-on treatment goals (Brenna et al., 2023). For this study, we use the term PAD to refer to any advance planning document (e.g., JCP, SBD) that individuals with mental health conditions may prepare with or without the help of another individual (e.g., a peer worker or a health care professional) to be used in the case of a mental health crisis.

PADs are intended to be crisis management documents. A systematic review of the content of PADs suggests that PADs generally contain six key areas: signs of crisis, general treatment approach, preferences regarding treatment setting, treatment preferences, coercion, and social instructions (e.g., who should be notified in cases of hospitalization and who may be able to visit) (Gaillard et al., 2023). In general, the preferences that individuals specify in PADs are highly individualized, as they are tailored to the person completing the PAD. Although PADs are intended to be used by inpatient and outpatient mental health care teams and emergency medical teams to guide patient care, the ability for health care teams to access these documents varies. First responders' inability to access a PAD during a crisis could result in transport to a nonpreferred setting of care (e.g., hospital). The legality and enforceability of these documents vary significantly, with some states and countries offering explicit legal support for PADs. The variability of enforceability may mean that a psychiatrist may not be legally obligated to try the medication the individual has specified in their PAD.

Although PADs have grown in popularity and their legality has been increasingly recognized in international contexts and among individual U.S. states, evidence for their use is not well synthesized or documented. Previous systematic reviews have focused narrowly on user experience (Braun et al., 2023), the content of PADs (Gaillard et al., 2023), implementation barriers (Francis, Johnson, and Wilson, 2024), or outcomes (Francis, Hazelton, and Wilson, 2024). This environmental scan takes a broader approach that combines evidence from systematic reviews, primary empirical literature, and grey literature to better understand the state of the evidence for implementing PADs in community, inpatient, and outpatient contexts.

Key Findings

• Many U.S. states and other countries legally recognize PADs.

• Evidence shows that PADs improve autonomy in decisionmaking, reduce coercion in crisis interventions, and lower involuntary hospitalization rates.

• Barriers to the integration of PADs in crisis planning and management include inconsistent legal recognition across states and jurisdictions, lack of provider understanding and training, and lack of awareness among persons with psychiatric conditions.

• Promising practices for PAD implementation include clinician training and awareness programs, facilitating PADs with peer worker or clinician support, and implementing clear legal mandates and frameworks.

• Future studies should focus on defining and measuring consistent outcomes for clinicians, individuals who have completed a PAD, and community members to increase the evidence regarding the use of PADs.

• Future implementation efforts should focus on ensuring that health care teams are aware of and trained to understand the legal status of PADs and how to use them within their current care environment.

This research was funded by California counties under the Mental Health Services Act and carried out within the Access and Delivery Program in RAND Health Care.