Psychiatric Advance Directives Empower Those with Mental Illnesses

You may have heard of “advanced directives” before, legal documents that allow someone to articulate what medical interventions they do or do not want performed on them, such as CPR or being put on a ventilator.  It can be an incredibly useful way for people to have their voices heard and honored in the medical process, particularly as they are facing end-of-life or difficult treatment options. But a less commonly discussed sub-genre of advanced directives is psychiatric advance directives, or PADs.  

The beauty of PADs is that they allow individuals with mental health issues to vocalize, in a moment of lucidity, how they want to be treated medically when they are experiencing a psychotic event. Many people with serious mental illness can be traumatized through involuntary hospitalizations or treatment with medication with terrible side effects and limited gain.  Tania Gergel at Slate shares that serious mental illnesses like bipolar, major depression, and psychosis tend to cycle through periods of stability and instability, and that people are often able to reflect during stable times on what helped or didn’t help during times of instability. Psychiatric advance directives recognize the wisdom people have gained through difficult previous experiences, and gives providers a head start on what might help de-escalate them this time around.  

Guidance for Providers and First Responders

Psychiatric advance directives may include a list of psychiatric medications the patient consents to taking, along with a list of what hasn’t worked for them and that they do not consent to receive again. Additionally PADs may list hospitals that the patient prefers to receive care at, authorize a surrogate decision maker with Durable Power of Attorney for Healthcare, and include a list of visitors who are allowed. Some may also include descriptions of how their mental health symptoms manifest or what sorts of phrases help them calm down in times of mania.

Harrison Pedigo, for instance, spoke with the New York Times about his psychiatric advance directive.  Pedigo suffers from schizophrenia and was hospitalized four times for hallucinations, babbling, and erratic behavior.  He created his psychiatric advance directive in 2016 and lists in it how his schizophrenia manifests, three medications and one hospital that he does not consent to, and allows the hospital to contact his parents.  He hasn’t been hospitalized since creating the PAD, but it allows him peace of mind, describing it as “a safety net… to help something not happen again or go smoother if it does.”

A psychiatric advance directive can give those with mental illness a sense of freedom and empowerment

Pedigo’s experience of the empowerment is not unique. A recent study published in J Ment Health showed that patients who completed PADs were half as likely as those who had not to receive coercive crisis treatments such as being placed in handcuffs, being taken by police to treatment, physical restraints, or forced medications.  The study hypothesized that creating a PAD allows a patient to become an active agent in their own care and helps them build a better collaborative relationship with their clinicians.  One anonymous study participant shared,

“I really felt like the hospital took better care of me because I had my PAD. In fact, I think it’s the best care that I’ve ever received . . . The doctor didn’t treat me like a nut case because some hospitals do. You know what the doctor said to me? [He said] ‘You’ve got rights and it’s great that you know you have them.’ That’s what he said.”

Tania Gergel also highlights that psychiatric advance directives can help patients not just avoid unwanted treatments, but actively ensure that they get treatment that they may be refusing at the time.  Gergel refers to this as self-binding aspects in directives, essentially committing themselves to a certain treatment for a future time when their unstable self may be refusing treatment. Using a PAD as self-binding allows for a healthy patient to communicate to a future provider exactly what treatment their unhealthy self would need.

Psychiatric advance directives are not perfect, requiring some time and energy to complete and get notarized.  Additionally, not all hospitals may be familiar with the concept of PADs, and there may be a limit to how much they can accommodate someone in a moment of crisis.  But a psychiatric advance directive offers a promising way to give some autonomy to people at their most vulnerable.