Advance directives for mental health care reduce mandatory admissions

Providing peer or community health workers assisting psychiatric patients with comprehensive psychiatric advance directives (PADs) to govern care before a mental health crisis is associated with a significant reduction in required hospitalizations, new research shows.

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

In addition to proving that PADs are effective in reducing compulsory admission, the results show that facilitation by peer helpers is relevant, study researcher Aurélie Tinland, MD, PhD, Faculty of Medicine Timone, Aix-Marseille University,

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

However, Tinland noted that more research including “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, so “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, says 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 establishments.

She added that prior care declarations are the most effective tool for reducing coercion, with one study suggesting they could reduce rates by 25% compared to usual care.

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

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

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

The PAD document included information about future treatment and support preferences, early signs of relapse, and coping strategies. The participants could meet the peer intervener in a place of their choice, be accompanied in writing the document and share it with the healthcare professionals.

A total of 394 people 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 an average of 37.4 years versus 41 years (P = 0.003) and were less likely to have one or more somatic comorbidities, at 61.2% versus 69.2%.

A PAD was completed by 54.6% of individuals in the intervention group versus 7.1% of controls (P

Results showed that the rate of compulsory admissions was significantly lower in the PAD peer worker group, at 27% versus 39.9% in control participants, at an odds ratio of 0.58 (P = 0.007).

Participants in the intervention group had lower symptoms on the Modified Colorado Symptom Score than patients in usual care with an effect size of -0.20 (P = 0.03) and higher scores on the empowerment scale (effect size 0.30, P = 0.003).

Scores on the Recovery Assessment Scale were also significantly higher in the peer worker PAD group compared to controls with an effect size of 0.44 (P

Place patients in the driver’s seat

Commenting on the findings of Medscape Medical NewsRobert Dabney Jr, MA, MDiv, director of the peer learning program at the Depression and Bipolar Support Alliance, Chicago, Illinois, said the study “tells us that there are many benefits to completing a guideline psychiatric prerequisite, but perhaps the most powerful is to put the person receiving mental health care in the driver’s seat of their own recovery.”

However, he noted that “many people living with mental health issues are unaware that there is an option to decide on their treatment plan before a crisis.”

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

“It is my personal hope and the goal of the Depression and Bipolar Support Alliance to enable more people to 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 NewsVirginia A. Brown, PhD, Department of Psychiatry & Behavioral Sciences, The University of Texas at Austin Dell Medical School, noted that there are huge differences between healthcare systems in France and the United States.

She explained that two of the biggest barriers to PADs in the United States are that until 2016 completing one was not billable and that “practitioners don’t know anything about advanced care plans.”

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

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

“There are a lot of hurdles we need to overcome to create a more robust system that protects the autonomy of people living with serious mental illness,” Brown said, because “the loss of capacity during a crisis is limited in time, and that forces us to respond to it as a medical emergency.”

The study was supported by a 2017 National Health Services Research Program Institutional Grant. The Clinical Research Directorate of Assistance Publique Hôpitaux de Marseille sponsored the trial. Tinland reports grants from the Department of Health’s Directorate General of Health Services (DGOS) during the conduct of the study.

European Psychiatric Association (EPA) Congress 2022. Summary: Facilitation of advance directives in psychiatry by peer-workers: results of the DAiP. Presented June 6, 2022.

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

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