Advance Directives for Psych Care Reduce Compulsory Admissions

Providing peer or community health workers to help psychiatric patients with complete psychiatric advance directives (PAD) to govern care in advance of a mental health crisis is associated with a significant reduction in compulsory hospital admissions, new research shows.

Results of a randomized trial showed the peer worker PAD group had a 42% reduction in compulsory admission over the following 12 months. This study group also had lower symptom scores, greater rates of recovery, and increased empowerment compared vs patients assigned to usual care.

In addition to proving that PADs are effective in reducing compulsory admission, the results show that facilitation by peer workers is relevant, study investigator Aurélie Tinland, MD, PhD, Faculté de Médecine Timone, Aix-Marseille University,

Marseille, France, told delegates attending the virtual European Psychiatric Association (EPA) 2022 Congress. The study was simultaneously published online June 6 in JAMA Psychiatry.

However, Tinland noted that more research that includes “harder to reach” populations is needed. In addition, greater use of PADs is also key to reducing compulsory admissions.

“Most Coercive” Country

The researchers note that respect for patient autonomy is a strong pillar of healthcare, such that “involuntary treatment should be unusual.” However, they point out that “compulsory psychiatric admissions are far too common in countries of all income levels.”

In France, said Tinland, 24% of psychiatric hospitalizations are compulsory. The country is ranked the sixth “most coercive” country in the world and there are concerns about human rights in French psychiatric facilities.

She added that advance care statements are the most efficient tool for reducing coercion, with one study suggesting they could cut rates by 25% compared with usual care.

However, she noted there is an “asymmetry” between medical professionals and patients and a risk of “undue influence” when clinicians facilitate the completion of care statements.

To examine the impact on clinical outcomes of peer-worker facilitated PADs, the researchers studied adults with a diagnosis of schizophrenia, bipolar I disorder, or schizoaffective disorder who were admitted to a psychiatric hospital within the previous 12 months. Peer workers are individuals who have lived experience with mental illness and help inform and guide current patients about care options in the event of a mental health crisis.

Study participants were randomly assigned 1:1 to an intervention group or a usual care control group. The intervention group received a PAD document and were assigned a peer worker while the usual care group received comprehensive information about the PAD concept at study entry and were free to complete it, but they were not connected with a peer worker.

The PAD document included information about future treatment and support preferences, early signs of relapse, and coping strategies. Participants could meet the peer worker in a place of their choice, be supported in drafting the document, and in sharing it with healthcare professionals.

In all, 394 individuals completed the study. The majority (61%) of participants were male and 66% had completed post-secondary education. Schizophrenia was diagnosed in 45%, bipolar I disorder in 36%, and schizoaffective disorder in 19%.

Participants in the intervention group were significantly younger than those in the control group, with a mean of 37.4 years vs 41 years (P = .003) and were less likely to have one or more somatic comorbidities, at 61.2% vs 69.2%.

A PAD was completed by 54.6% of individuals in the intervention group vs 7.1% of controls (P < .001). The PAD was written with peer worker support by 41.3% of those in the intervention and by 2% of controls. Of those who complete a PAD, 75.7% met care facilitators and 27.1% used it during a crisis over the following 12 months.

Results showed that the rate of compulsory admissions was significantly lower in the peer worker PAD group, at 27% vs 39.9% in control participants, at an odds ratio of 0.58 (P = .007).

Participants in the intervention group had lower symptoms on the modified Colorado Symptom Score than usual care patients with an effect size of -0.20 (P = .03) and higher scores on the Empowerment Scale (effect size 0.30, P = .003).

Scores on the Recovery Assessment Scale were also significantly higher in the peer worker PAD group vs controls with an effect size of 0.44 (P < .001). There were no significant differences, however, in overall admission rates, the quality of the therapeutic alliance, and quality of life.

Putting Patients in the Driver’s Seat

Commenting on the findings for Medscape Medical News, Robert Dabney Jr, MA, MDiv, peer apprentice program manager at the Depression and Bipolar Support Alliance, Chicago, Illinois, said the study “tells us there are many benefits to completing a psychiatric advance directive, but perhaps the most powerful one is putting the person receiving mental healthcare in the driver’s seat of their own recovery.”

However, he noted that “many people living with mental health conditions don’t know the option exists to decide on their treatment plan in advance of a crisis.”

“This is where peer support specialists can come in. Having a peer who has been through similar experiences and can guide you through the process is as comforting as it is empowering. I have witnessed and experienced firsthand the power of peer support,” he said.

“It’s my personal hope and the goal of the Depression and Bipolar Support Alliance to empower more people to either become peer support specialists or seek out peer support services because we know it improves and even saves lives,” Dabney added.

Also commenting for Medscape Medical News, Virginia A. Brown, PhD, Department of Psychiatry & Behavioral Sciences, The University of Texas at Austin Dell Medical School, noted there are huge differences between the healthcare systems in France and the United States.

She explained that two of the greatest barriers to PADs in the US is that until 2016, filling one out was not billable, and that “practitioners don’t know anything about advanced care plans.”

Brown said her own work shows that individuals who support patients during a crisis believe it would be “really helpful if we had some kind of document that we could share with the healthcare system that says: ‘Hey, look, I’m the designated person to speak for this patient, they’ve identified me through a document.’ So, people were actually describing a need for this document, but didn’t know that it existed.”

Another problem is that in the US, hospitals operate in a “closed system” and cannot talk to an unrelated hospital or to the police department “to get information to those first responders during an emergency about who to talk to about their wishes and preferences.”

“There are a lot of hurdles that we’ve got to get over to make a more robust system that protects the autonomy of people who live with serious mental illness,” Brown said, as “losing capacity during a crisis is time-limited, and it requires us to respond to it as a medical emergency.”

The study was supported by an institutional grant from the French 2017 National Program of Health Services Research. The Clinical Research Direction of Assistance Publique Hôpitaux de Marseille sponsored the trial. Tinland declares grants from the French Ministry of Health Directorate General of Health Care Services (DGOS) during the conduct of the study.

European Psychiatric Association (EPA) 2022 Congress. Abstract: Facilitation of Psychiatric Advance Directives by Peer-Workers: Results from DAiP. Presented June 6, 2022.

JAMA Psych. Published online June 6, 2022. Full text

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