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A Review of Barriers to Using Psychiatric Advance Directives in Clinical Practice

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Abstract

Despite advocacy and demand for psychiatric advance directives (PADs), uptake and implementation in clinical practice is low. We examine why PAD implementation has been difficult globally by reviewing barriers in existing evidence. The review includes 30 studies, and identified 13 barriers, clustered into system level barriers, health professional level barriers, and service user level barriers. The considerable barriers to uptake and implementation hamper PAD use. We propose several potential strategies for overcoming some of the barriers. In order to realise these strategies, additional research is needed, particularly more field-based and operational research to understand processes and difficulties experienced in clinical practice.

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Notes

  1. The authors define a Ulysses directive as a subset of PADs, where a client with recurrent psychiatric episodes not yet deemed dangerous provides permission in advance for admission and treatment, thus forfeiting the right to refuse them. The key issue with Ulysses directives is the notion of irrevocability (Varekamp 2004).

References

  • Alem, A., Jacobsson, L., Lynöe, N., Kohn, R., & Kullgren, G. (2002). Attitudes and practices among Ethiopian health care professionals in psychiatry regarding compulsory treatment. International Journal of Law and Psychiatry, 25(6), 599–610.

    Article  PubMed  Google Scholar 

  • Ambrosini, D. L., Bemme, D., Crocker, A. G., & Latimer, E. (2012). Narratives of individuals concerning psychiatric advance directives: Qualitative study. Journal of Ethics in Mental Health, 6(1), 1–9.

    Google Scholar 

  • Ambrosini, D., Crocker, A. G., Perreault, M., & Israël, M. (2008). Perceptions of psychiatric advance directives among legal and mental health professionals in Ontario and Quebec. Journal of Ethics in Mental Health, 3(1), 1–12.

    Google Scholar 

  • Amering, M., Denk, E., Griengl, H., Sibitz, I., & Stastny, P. (1999). Psychiatric wills of mental health professionals: A survey of opinions regarding advance directives in psychiatry. Social Psychiatry and Psychiatric Epidemiology, 34(1), 30–34.

    Article  PubMed  CAS  Google Scholar 

  • Amering, Michaela, Stastny, P., & Hopper, K. (2005). Psychiatric advance directives: Qualitative study of informed deliberations by mental health service users. The British Journal of Psychiatry, 186, 247–252.

    Article  PubMed  Google Scholar 

  • Atkinson, J. M., Garner, H. C., & Gilmour, W. H. (2004). Models of advance directives in mental health care: Stakeholder views. Social Psychiatry and Psychiatric Epidemiology, 39(8), 673–680.

    Article  PubMed  Google Scholar 

  • Atkinson, J. M., Garner, H. C., Stuart, S., & Patrick, H. (2003). The development of potential models of advance directives in mental health care. Journal of Mental Health, 12(6), 575–584.

    Article  Google Scholar 

  • Backlar, P. (1997). Anticipatory planning for psychiatric treatment is not quite the same as planning for end-of-life care. Community Mental Health Journal, 33(4), 261–268.

    Article  PubMed  CAS  Google Scholar 

  • Backlar, P., McFarland, B. H., Swanson, J. W., & Mahler, J. (2001). Consumer, provider, and informal caregiver opinions on psychiatric advance directives. Administration and Policy in Mental Health, 28(6), 427–441.

    Article  PubMed  CAS  Google Scholar 

  • Campbell, L. A., & Kisely, S. R. (2009). Advance treatment directives for people with severe mental illness. Cochrane database of systematic reviews, 1, CD005963. doi:10.1002/14651858.CD005963.

    PubMed  Google Scholar 

  • Elbogen, E. B., Swanson, J. W., Appelbaum, P. S., Swartz, M. S., Ferron, J., Van Dorn, R., et al. (2007a). Competence to complete psychiatric advance directives: Effects of facilitated decision making. Law and Human Behavior, 31(3), 275–289.

    Article  PubMed  Google Scholar 

  • Elbogen, E. B., Swanson, J. W., Swartz, M. S., Van Dorn, R., Ferron, J., Wagner, H. R., et al. (2007b). Effectively implementing psychiatric advance directives to promote self-determination of treatment among people with mental illness. Psychology Public Policy and Law, 13(4), 273–288.

    Article  Google Scholar 

  • 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, 57(3), 350–355.

    Article  PubMed  Google Scholar 

  • Foy, J., Macrae, A., Thom, A., & Macharouthu, A. (2007). Advance statements: Survey of patients’ views and understanding advance. Psychiatric Bulletin, 31, 339–341.

    Article  Google Scholar 

  • Hanlon, C., Tesfaye, M., Wondimagegn, D., & Shibre, T. (2010). Ethical and professional challenges in mental health care in low- and middle-income countries. International Review of Psychiatry, 22(3), 245–251.

    Article  PubMed  Google Scholar 

  • Henderson, C., Jackson, C., Slade, M., Young, A. S., & Strauss, J. L. (2010). How should we implement psychiatric advance directives? Views of consumers, caregivers, mental health providers and researchers. Administration and Policy in Mental Health, 37(6), 447–458.

    Article  PubMed  Google Scholar 

  • Henderson, C., Swanson, J. W., Szmukler, G., Thornicroft, G., & Zinkler, M. (2008). A typology of advance statements in mental health care. Psychiatric Services, 59(1), 63–71.

    Article  PubMed  Google Scholar 

  • Jankovic, J., Richards, F., & Priebe, S. (2010). Advance statements in adult mental health. Advances in Psychiatric Treatment, 16(6), 448–455.

    Article  Google Scholar 

  • Kim, S. Y. H., Appelbaum, P. S., Swan, J., Stroup, T. S., McEvoy, J. P., Goff, D. C., et al. (2007). Determining when impairment constitutes incapacity for informed consent in schizophrenia research. The British Journal of Psychiatry, 191, 38–43.

    Article  PubMed  Google Scholar 

  • Kim, M. M., Scheyett, A. M., Elbogen, E. B., Van Dorn, R. A., McDaniel, L. A., Swartz, M. S., et al. (2008). Front line workers’ attitudes towards psychiatric advance directives. Community Mental Health Journal, 44(1), 28–46.

    Article  PubMed  Google Scholar 

  • Kumar, T. C. R., John, S., Gopal, S., Mohan, G., Joseph, J., Study Group, et al. (2013). Psychiatric advance statements: An Indian experience. The International Journal of Social Psychiatry, 59(6), 531–534.

    Article  PubMed  Google Scholar 

  • Laugharne, R., & Priebe, S. (2006). Trust, choice and power in mental health: A literature review. Social Psychiatry and Psychiatric Epidemiology, 41(11), 843–852.

    Article  PubMed  Google Scholar 

  • Miller, R. D. (1998). Advance directives for psychiatric treatment: A view from the trenches. Psychology Public Policy and Law, 4(3), 728–745.

    Article  CAS  Google Scholar 

  • Mills, E., Jadad, A. R., Ross, C., & Wilson, K. (2005). Systematic review of qualitative studies exploring parental beliefs and attitudes toward childhood vaccination identifies common barriers to vaccination. Journal of Clinical Epidemiology, 58(11), 1081–1088.

    Article  PubMed  Google Scholar 

  • O’Connell, M. J., & Stein, C. H. (2005). Psychiatric advance directives: Perspectives of community stakeholders. Administration and Policy in Mental Health, 32(3), 241–265.

    Article  PubMed  Google Scholar 

  • Patel, V., & Bloch, S. (2009). The ethical imperative to scale up health care services for people with severe mental disorders in low and middle income countries. Postgraduate Medical Journal, 85(1008), 509–513.

    Article  PubMed  CAS  Google Scholar 

  • Peto, T., Srebnik, D., Zick, E., & Russo, J. (2004). Support needed to create psychiatric advance directives. Administration and Policy in Mental Health, 31(5), 409–419.

    Article  PubMed  Google Scholar 

  • Rajkumar, A. P., Saravanan, B., & Jacob, K. S. (2006). Perspectives of patients and relatives about electroconvulsive therapy: A qualitative study from Vellore India. The Journal of ECT, 22(4), 253–258.

    Article  PubMed  Google Scholar 

  • Reilly, J., & Atkinson, J. M. (2010). The content of mental health advance directives: Advance statements in Scotland. International Journal of Law and Psychiatry, 33(2), 116–121.

    Article  PubMed  Google Scholar 

  • Ruchlewska, A., Mulder, C. L., Van der Waal, R., Kamperman, A., & Van der Gaag, M. (2012). Crisis plans facilitated by patient advocates are better than those drawn up by clinicians: Results from an RCT. Administration and Policy in Mental Health. doi:10.1007/s10488-012-0454-4.

  • Scheyett, A., Kim, M., Swanson, J., & Swartz, M. (2009). Social work in mental health autonomy and the use of directive intervention in the treatment of individuals with serious mental illnesses: A survey of social work practitioners. Social Work in Mental Health, 7(4), 283–306.

    Article  Google Scholar 

  • Scheyett, A. M., Vaughn, J. S., & Francis, A. M. (2010). Jail administrators’ perceptions of the use of psychiatric advance directives in jails. Psychiatric Services, 61(4), 409–411.

    Article  PubMed  Google Scholar 

  • Srebnik, D. (2005). Issues in applying advance directives to psychiatric care in the United States. Australasian Journal on Ageing, 24(Supplement S1), S42–S45.

    Google Scholar 

  • Srebnik, D., & Brodoff, L. (2003). Implementing psychiatric advance directives: Service provider issues and answers. The Journal of Behavioural Health Services and Research, 30(3), 253–268.

    Article  Google Scholar 

  • Srebnik, D. S., & Russo, J. (2007). Consistency of psychiatric crisis care with advance directive instructions. Psychiatric Services, 58(9), 1157–1163.

    Article  PubMed  Google Scholar 

  • Srebnik, D. S., & Russo, J. (2008). Use of psychiatric advance directives during psychiatric crisis events. Administration and Policy in Mental Health, 35(4), 272–282.

    Article  PubMed  Google Scholar 

  • 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(7), 981–986.

    Article  PubMed  Google Scholar 

  • Srebnik, D. S., Rutherford, L. T., Peto, T., Russo, J., Zick, E., Jaffe, C., et al. (2005). The content and clinical utility of psychiatric advance directives. Psychiatric Services, 56(5), 592–598.

    Article  PubMed  Google Scholar 

  • Swanson, J. W., Swartz, M. S., Elbogen, E. B., Van Dorn, R., Ferron, J., Wagner, H. R., et al. (2006a). Facilitated psychiatric advance directives: A randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. The American Journal of Psychiatry, 163(11), 1943–1951.

    Article  PubMed  PubMed Central  Google Scholar 

  • Swanson, J. W., Swartz, M. S., Elbogen, E. B., Van Dorn, R. A., Wagner, H. R., Moser, L. A., et al. (2008). Psychiatric advance directives and reduction of coercive crisis interventions. Journal of Mental Health, 17(3), 255–267.

    Article  PubMed  PubMed Central  Google Scholar 

  • Swanson, J., Swartz, M., Ferron, J., Elbogen, E., & Van Dorn, R. (2006b). Public mental health consumers in five US Cities: Prevalence, demand, and correlates. Journal of the American Academy of Psychiatry and Law, 34(1), 43–57.

    Google Scholar 

  • Swanson, J. W., Swartz, M. S., Hannon, M. J., Elbogen, E. B., Wagner, H. R., McCauley, B. 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(1), 73–86.

    Article  Google Scholar 

  • Swanson, J. W., Tepper, M. C., Backlar, P., & Swartz, M. S. (2000). Psychiatric advance directives: An alternative to coercive treatment? Psychiatry, 63(2), 160–172.

    PubMed  CAS  Google Scholar 

  • Swanson, J. W., Van McCrary, S., Swartz, M. S., Van Dorn, R. A., & Elbogen, E. B. (2007). Overriding psychiatric advance directives: Factors associated with psychiatrists’ decisions to preempt patients’ advance refusal of hospitalization and medication. Law and Human Behavior, 31(1), 77–90.

    Article  PubMed  Google Scholar 

  • Swartz, M. S., Swanson, J. W., Ferron, J., Elbogen, E. B., Van, R., Kim, M., et al. (2005). Psychiatrists’ views and attitudes about psychiatric advance directives. International Journal of Forensic Mental Health, 4(2), 37–41.

    Article  Google Scholar 

  • Swartz, M. S., Swanson, J. W., Van Dorn, R. A., Elbogen, E. B., Carolina, N., & Shumway, M. (2006). Patient preferences for psychiatric advance directives. International Journal of Forensic Mental Health, 5(1), 37–41.

    Article  Google Scholar 

  • Thara, R., & Rameshkumar, T. C. (2012). Psychiatric advance directives: Challenges of implementation. Indian Journal of Medical Ethics, 9(2), 108.

    PubMed  CAS  Google Scholar 

  • United Nations (2006) Convention on the Rights of Persons with Disabilities and Optional Protocol. Adopted on 13 December, 2006. Resolution A/RES/61/106.

  • Van der Ham, A. J., Voskes, Y., van Kempen, N., Broerse, J. E. W., & Widdershoven, G. A. (2013). The implementation of psychiatric advance directives: Experiences from a Dutch crisis card initiative. Psychiatric Rehabilitation Journal, 36(2), 119–121. doi:10.1037/h0094983.

    Article  PubMed  Google Scholar 

  • Van Dorn, R. A., Swanson, J. W., & Swartz, M. S. (2009). Preferences for psychiatric advance directives among Latinos: Views on advance care planning for mental health. Psychiatric Services, 60(10), 1383–1385.

    PubMed  PubMed Central  Google Scholar 

  • Van Dorn, R. A., Swanson, J. W., Swartz, M. S., Elbogen, E., & Ferron, J. (2008). Reducing barriers to completing psychiatric advance directives. Administration and Policy in Mental Health, 35(6), 440–448.

    Article  PubMed  PubMed Central  Google Scholar 

  • Van Dorn, R. A., Swartz, M. S., Elbogen, E. B., Swanson, J. W., Kim, M., Ferron, J., et al. (2006). Clinicians’ attitudes regarding barriers to the implementation of psychiatric advance directives. Administration and Policy in Mental Health, 33(4), 449–460.

    Article  PubMed  Google Scholar 

  • Varekamp, I. (2004). Ulysses directives in The Netherlands: Opinions of psychiatrists and clients. Health Policy, 70(3), 291–301.

    Article  PubMed  CAS  Google Scholar 

  • Wauchope, B., O’Kearney, R., Bone, L., & Urbanc, A. (2011). Advance agreements for mental health care: An examination of process and outcomes. The Australian and New Zealand Journal of Psychiatry, 45(4), 281–288.

    Article  PubMed  Google Scholar 

  • Weller, P. (2010). Developing law and ethics: The convention on the rights of persons with disabilities. Alternative Law Journal, 35(1), 8–12.

    Google Scholar 

  • Wilder, C. M., Elbogen, E. B., Swartz, M. S., Swanson, J. W., & Van Dorn, R. A. (2007). Effect of patients’ reasons for refusing treatment on implementing psychiatric advance directives. Psychiatric Services, 58(10), 1348–1350.

    Article  PubMed  Google Scholar 

  • Wilder, C. M., Swanson, J. W., Bonnie, R. J., Wanchek, T., McLaughlin, L., & Richardson, J. (2012). A survey of stakeholder knowledge, experience and opinions of advance directives for mental health in Virginia. Administration and Policy in Mental Health, 40(3), 232–239. doi:10.1007/s10488-011-0401-9.

    Article  Google Scholar 

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Authors and Affiliations

  1. Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands

    Laura S. Shields, A. J. van der Ham & Joske Bunders

  2. Mental Health Law and Policy Lab, Centre for Mental Health Law and Policy, Indian Law Society, Pune, India

    Laura S. Shields & Soumitra Pathare

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  1. Laura S. Shields
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  2. Soumitra Pathare
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  3. A. J. van der Ham
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  4. Joske Bunders
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Correspondence to Laura S. Shields.

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Shields, L.S., Pathare, S., van der Ham, A.J. et al. A Review of Barriers to Using Psychiatric Advance Directives in Clinical Practice. Adm Policy Ment Health 41, 753–766 (2014). https://doi.org/10.1007/s10488-013-0523-3

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