How Should we Implement Psychiatric Advance Directives? Views of Consumers, Caregivers, Mental Health Providers and Researchers

  • Claire Henderson
  • Carlos Jackson
  • Mike Slade
  • Alexander S. Young
  • Jennifer L. Strauss
Original Paper


The aim of this study was to measure expert consensus on the implementation of Psychiatric Advance Directives (PADs) within the Veterans Health Administration. We conducted a two-round Delphi study with 55 panelists including consumers, caregivers, mental health providers and researchers. For a number of items where no positive or negative consensus was reached we found differences between the views of consumers and non-consumers, reflecting consumer’s preferences for nonmedical settings for completion and assistance with completion independent of the treatment team. Thus, the principle of consumer choice that applies to MHAD content should also be applied to the process of completion offered.


Psychiatric advance directives Consensus study Implementation 



We wish to thank Andrea Jamison, PhD, James J Peters VA Medical Center; Antonette Zeiss, PhD, VA Central Office; Robert A. Pearlman, MD, MPH, Chief, Ethics Evaluation, National Center for Ethics in Health Care (VHA) and Ruth Cecire, PhD, Policy Analyst, National Center for Ethics in Health Care for providing the draft worksheets and information on the plans for implementation of the VA MHAD; Daniel Herman, PhD, and Helen Rasmussen, M.S.W., for comments on drafts of the questionnaire. Michaela Amering, Patricia Backlar, Toni Beard, Tom Berger, Daniel Bradford, Loretta Braxton, Roy Brown, Jennifer Bucci, William Crandell, Deb Define, Dianna Dragatsi, Eric Elbogen, Ann Feder, Chris Flood, Mary Ellen Foti, Bert Harvey, John Hendershot, Peggy Henderson, Scott Hicks, Shirley Holland, Teresa Isner, Thomas Kallert, Miriam Keith, Mimi Kim, Lona King, Doreen Krodel, Rufina Lee, Stephanie LeMelle, Miklos Losonczy, David Lowenthal, James McDonagh, Hunter McQuistion, Susan Mirch-Kertschmann, Mary Nettle, Maria O’Connell, consumer advocate (name withheld), Melody Riefer, Diana Rose, Jana Spalding, Kim Sutherby, Jeffrey Swanson, Marvin Swartz, George Szmukler, John Tatarakis, Gaila Taylor, Crescent Terry, Graham Thornicroft, Richard van Dorn, Colleen Vaughan, Kendra Weaver, Jacqueline Woo, Carol Youtz, Laura Ziegler, Martin Zinkler. The views expressed in this article are those of the authors and do not necessarily reflect the positions or policies of affiliated institutions. This study was supported by the Department of Veterans Affairs Health Services Research and Development Service # SHP-08-163 and by a Department of Veterans Affairs Research Career Development Award to the last author #RCD-06-020. James J. Peters in VA Medical Center at that time the study was conducted.


  1. Annas, G. J. (1995). How we lie. Hastings Center Report, 25, S12–S14.PubMedGoogle Scholar
  2. Atkinson, J. M., Garner, H. C., & Gilmour, W. H. (2004). Models of advance directives in mental health care: Stakeholders’ views. Social Psychiatry and Psychiatric Epidemiology, 39, 673–680.CrossRefPubMedGoogle Scholar
  3. Campbell, S. M., Cantrill, J. A., & Roberts, D. (2000). Prescribing indicators for UK general practice: Delphi consultation study. British Medical Journal, 321, 425–428.CrossRefPubMedGoogle Scholar
  4. Elbogen, E. B., Swartz, M. S., Van Dorn, R., Swanson, J. W., Kim, M., & Scheyett, A. (2006). Clinical decision making and views about psychiatric advance directives. Psychiatric Services, 572, 350–355.CrossRefGoogle Scholar
  5. VHA Handbook 1004.2, “Advance Care Planning and Management of Advance Directives”.
  6. Henderson, C., Flood, C., Leese, M., et al. (2009). Views of patients and providers on joint crisis plans: single blind randomized controlled trial. Social Psychiatry and Psychiatric Epidemiology, 44(5), 369–376.CrossRefPubMedGoogle Scholar
  7. Henderson, C., Flood, C., Leese, M., Thornicroft, G., Sutherby, K., & Szmukler, G. (2004). Effect of joint crisis plans on use of compulsory treatment in psychiatry: Single blind randomised controlled trial. British Medical Journal, 329, 136.CrossRefPubMedGoogle Scholar
  8. Jones, J., & Hunter, D. (1995). Consensus methods for medical and health services research. British Medical Journal, 311, 376–380.PubMedGoogle Scholar
  9. Kim, M. M., Scheyett, A. M., Elbogen, E. B., et al. (2007). Front line workers’ attitudes towards psychiatric advance directives. Community Mental Health Journal, 44, 28–46.CrossRefPubMedGoogle Scholar
  10. Leslie, D. L., & Rosenheck, R. (2006). Eighth annual report on Schizophrenia Pharmacotherapy in VA. West Haven, CT: VA Connecticut MIRECC and NEPEC.Google Scholar
  11. Mohan, R., Slade, M., & Fahy, T. A. (2004). Clinical characteristics of community forensic mental health services. Psychiatric Services, 55, 1294–1298.CrossRefPubMedGoogle Scholar
  12. Murphy, M. K., Black, N., Lamping, D. L., McKee, C. M., Sanderson, C. F. B., Askham, J., et al. (1998). Consensus development methods and their use in clinical guideline development. Health Technology Assessment, 2, 3.Google Scholar
  13. National Ethics Committee of the Veterans Health Administration. (2008). Advance directives for mental health: An ethical analysis of state laws & implications for VHA policy. Washington, DC, National Center for Ethics in Health Care, Veterans Health Administration. Department of Veterans Affairs.Google Scholar
  14. Papageorgiou, A., King, M., Janmohamed, A., et al. (2002). Advance directives for patients compulsorily admitted to hospital with serious mental illness: Randomised controlled trial. British Journal of Psychiatry, 181, 513–519.CrossRefPubMedGoogle Scholar
  15. Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health and Mental Health Services Research, 36, 24–34.CrossRefPubMedGoogle Scholar
  16. Slade, M., Powell, R., Rosen, A., & Strathdee, G. (2000). Threshold Assessment Grid (TAG): The development of a valid and brief scale to asess the severity of mental illness. Social Psychiatry and Psychiatric Epidemiology, 35, 78–85.CrossRefPubMedGoogle Scholar
  17. Srebnik, D. S., & Russo, J. (2007). Consistency of psychiatric crisis care with advance directive instructions. Psychiatric Services, 58, 1157–1163.CrossRefPubMedGoogle Scholar
  18. Srebnik, D. S., Russo, J., Sage, J., Peto, T., & Zick, E. (2003). Interest in psychiatric advance directives among high users of crisis services and hospitalization. psychiatric Services, 54, 981–986.CrossRefPubMedGoogle Scholar
  19. Srebnik, D. S., Rutherford, L. T., Peto, T., et al. (2005). The content and clinical utility of psychiatric advance directives. Psychiatric Services, 56, 592–598.CrossRefPubMedGoogle Scholar
  20. Stetler, C. B., Legro, M. W., Wallace, C. M., Bowman, C., Guihan, M., Hageodorn, H., et al. (2006). The role of formative evaluation in implementation research and the QUERI experience. Journal of General Internal Medicine, 21(Suppl 2), S1–S8.CrossRefPubMedGoogle Scholar
  21. Strauss, J. L., O’Loughlin, S. H., Keng, S., Stechuchak, K. M., Olsen, M. K., & Zervakis, J. B., et al. (2007). Content analysis of psychiatric advance directives: treatment preferences expressed by veterans with severe mental illness. Poster presented at the Annual HSR & D Career Development Conference. Arlington, VA.Google Scholar
  22. Strauss, J. L., Stechuchak, K. M., & Olsen, M. K., et al. (2008). Results from a randomized controlled trial to facilitate the use of psychiatric advance directives: lessons learned. Abstract presented at the 26th annual health services research and development meeting. Baltimore, MD.Google Scholar
  23. SUPPORT Principal Investigators. (1995). A controlled trial to improve care for the seriously ill hospitalized patient: The study to understand prognosis for outcomes and risk of treatments (SUPPORT). Journal of the American Medical Association, 274, 1591–1598.CrossRefGoogle Scholar
  24. Swanson, J. W., Swartz, M. S., Elbogen, E. B., et al. (2006a). Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. American Journal of Psychiatry, 163, 1943–1951.CrossRefPubMedGoogle Scholar
  25. Swanson, J. W., Swartz, M. S., Elbogen, E. B., et al. (2008). Psychiatric advance directives and reduction of coercive crisis interventions. Journal of Mental Health, 17, 255–267.CrossRefPubMedGoogle Scholar
  26. Swanson, J., Swartz, M., Ferron, J., et al. (2006b). Psychiatric advance directives among public mental health consumers in five U.S. cities: Prevalence, demand, and correlates. The journal of the American Academy of Psychiatry and the Law, 34, 43–57.PubMedGoogle Scholar
  27. Swanson, J. W., Swartz, M. S., Hannon, M. J., et al. (2003). Psychiatric advance directives: a survey of persons with schizophrenia, family members, and treatment providers. International Journal of Forensic Mental Health, 2, 73–86.Google Scholar
  28. US Department of Veterans Affairs. (2004). VHA Comprehensive Mental Health Strategic Plan.Google Scholar
  29. Van Dorn, R. A., Swartz, M. S., Elbogen, E. B., et al. (2006). Clinicians’ attitudes regarding barriers to the implementation of psychiatric advance directives. Administration and Policy In Mental Health, 33, 449–460.CrossRefPubMedGoogle Scholar
  30. Yu, W., Ravelo, A., Wagner, T. H., et al. (2003). Prevalence and costs of chronic conditions in the VA health care system. Medical Care Research and Review, 60(3), 146S–167S. (Supplement to September 2003).CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Claire Henderson
    • 1
    • 2
  • Carlos Jackson
    • 2
    • 3
  • Mike Slade
    • 1
  • Alexander S. Young
    • 4
  • Jennifer L. Strauss
    • 5
  1. 1.P029, Health Service and Population Research DepartmentInstitute of Psychiatry, King’s College LondonLondonUK
  2. 2.James J. Peters VA Medical CenterBronxUSA
  3. 3.New York State Psychiatric InstituteColumbia UniversityNew YorkUSA
  4. 4.Greater Los Angeles VA and University of California Los AngelesLos AngelesUSA
  5. 5.Durham VA and Duke University Medical CentersDurhamUSA

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