BACKGROUND/RATIONALE:
During a psychiatric crisis, persons with severe mental illness (SMI) confront complex challenges concerning treatment choices and are often ill equipped or unable to make mental health care decisions. Psychiatric Advance Directives (PADs) are legal documents that allow competent persons to declare their treatment preferences in advance of a mental health crisis, when they may lose capacity to make reliable health care decisions. The use of PADs is consistent with recommendations of the President’s New Freedom Commission on Mental Illness and the Patient Self-Determination Act; 25 states have now adopted PAD legislation. VA does not have a specific policy for PADs or mechanisms to notify veterans of their right to prepare PADs. The downstream effects of PADs on patient care, crisis management, service use, and clinical outcomes are unknown.


OBJECTIVE(S):
This project examined the effects of a facilitated PAD intervention on guiding patients’ treatment during a future mental health crisis, patients’ treatment engagement, and patients’ mental health service use and clinical outcomes. An additional objective was to describe veterans’ preferences for PAD content and completion. Study hypotheses predicted that, as compared to controls, veterans with PAD would have fewer involuntary hospitalizations, great satisfaction with care, less coercion and more autonomy, greater treatment motivation, stronger working alliances, less ER use and fewer rehospitalizations, and improved clinical outcomes.

METHODS:
A total of 240 psychiatrically hospitalized veterans with severe mental illness were enrolled in this prospective, randomized, clinical intervention trial: 120 were randomized to “usual care” and received information about PADs; 120 were randomized to the PAD condition. All participants and their clinicians received information about PADs. Those randomized to the PAD condition were also offered the opportunity to complete a facilitated PAD. The facilitated PAD consisted of a 60-minute meeting with a clinician, who provided education about PADs and conducted a semi-structured interview to assess the patient’s wishes and preferences for future treatment during a mental health crisis. The clinician then assisted the patient to prepare a PAD document. Patients in both groups completed follow-up assessments at 1, 6, and 12 months post-enrollment. Those rehospitalized at Durham VAMC during the 12-month follow up period completed an additional assessment interview at each rehospitalization.

FINDINGS/RESULTS:
Those randomized to the PAD group did not differ from those who received Usual Care on the primary study outcomes. Analyses of PAD content indicate that patients with severe mental illness can clearly specify treatment preferences in PADs and that PADs provide information that may be clinically useful. The majority of those who completed a PAD reported being extremely or moderately satisfied with their PADs. Approximately half reported positive effects as a result of their PADs. A minority (1.6% at 1-month follow up, 12.9% at 12-month follow up) reported that their PADs were used in their health care. Qualitative feedback suggests that those who completed a PAD felt empowered, that the experience provided clarity and insight, and that PADs are a useful tool for communicating treatment preferences to physicians and families.

IMPACT:
This study demonstrates that veterans with severe mental illness can complete clinically relevant advance instructions in a facilitated PAD and that veterans are satisfied with PADs. This study also yielded two transportable products: a tested manual for facilitating PADs and a progress note template for PAD documentation in CPRS.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Zervakis JB, Stechuchak KM, Olsen MK, Swanson JW, Oddone EZ, Weinberger M, Bryce ER, Butterfield ML, Swartz MS, Strauss JL. Previous Involuntary Commitment is Associated with Current Perceptions of Coercion in Voluntarily Hospitalized Patients. International Journal of Forensic Mental Health. 2007 Nov 1; 6(No. 2):105-112. [view]
2. Elbogen E, Strauss JL, Swanson J, Swartz M, Butterfield MI. Psychiatric Advance Directives: A primer for North Carolina mental health providers. North Carolina Psychologist. 2004 Jan 1; 56(1):1-3. [view]

Conference Presentations

1. Butterfield M, Stechuchak K, Olsen M, Strauss JL, Zervakis J, O'loughlin S, Roland J, Swartz M, Oddone EZ, Weinberger M. Adverse Impact of Involuntary Hospitalization on Perceptions of Psychiatric Care in Veterans. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA. [view]
2. Butterfield M, Stechuchak K, Strauss JL, Zervakis J, O'loughlin S, Roland J, Swartz M, Olsen M, Weinberger M, Oddone E. Adverse impact of involuntary hospitalization on perceptions of psychiatric care in veterans with severe mental illness. Paper presented at: American Psychiatric Association Annual Meeting; 2006 May 1; Toronto, Canada. [view]
3. Strauss JL, O'Loughlin S, Keng SL, Stechuchak K, Olsen M, Zervakis J, Elbogen E, Oddone EZ, Weinberger M, Swartz M, Butterfield ML. Content analysis of psychiatric advance directives: treatment preferences expressed by veterans with sever mental illness. Poster session presented at: VA HSR&D National Meeting; 2006 Nov 1; Arlington, VA. [view]
4. Zervakis J, Stechuchak K, Olsen M, Strauss JL, Oddone E, Weinberger M, O'loughlin S, Roland J, Butterfield M. Involuntary commitment influences perceptions of coercion in psychiatrically hospitalized veterans. Paper presented at: American Psychiatric Association Annual Meeting; 2006 May 1; Toronto, Canada. [view]
5. Butterfield MI, Strauss J, Oddone EZ, Weinberger M, Wampler T, Zervakis J. Psychiatric Advance Directives: Issues for Veterans with Mental Illness. Paper presented at: American Psychiatric Association Annual Meeting; 2005 May 15; Atlanta, GA. [view]
6. Strauss JL. Results from a randomized controlled trial to facilitate the use of psychiatric advance directives: Lessons learned. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational, Technology Development and Assessment
Keywords: Advance directives, Cognitive impairment, Patient outcomes
MeSH Terms: none