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    Psychiatric Advance Directives

    Patients often experience a lack of full control over important treatment decisions about their mental health, especially during times of mental health crisis. This can lead to suffering for patients and frustration for their families. Psychiatric advance directives (PADs) provide an opportunity for patients to outline their preferences about their mental health treatment in the event that they become unable to make such decisions for themselves in the future.

    A PAD is a legal document in which patients can describe the types of mental health treatments that they would or would not be willing to receive. Patients can also use a PAD to appoint an authorized decisionmaker, or agent, to make mental health treatment decisions on their behalf. Physicians can use PADs to get a clearer understanding of the patient’s treatment preferences, how to best support the patient during crisis, and who to contact about the patient’s mental health care. PADs serve as a way to protect a patient’s autonomy over treatment decisions and to enable families to assist their loved ones in a crisis.

    Psychiatric advance directives

    • Preserves patient autonomy.
    • Facilitates communication between a physician and patient about important treatment decisions that may prevent crises from occurring. 
    • Improves continuity of care.
    • Facilitates timely interventions.
    • Helps with accessing care that aligns with patient preferences.
    • Enhances collaboration with the treatment team.
    • Reduces use of involuntary treatment.
    • Provides a mechanism for families or other loved ones to officially be involved in treatment.

    Medical Advance Directives, which are more common and may be more familiar, were designed to help patients control decisions about end-of-life care, for instance, by withholding medical treatments that do not provide a meaningful quality of life for patients who are terminally ill. All states permit some type of medical advance directives. These directives typically authorize an agent to make medical decisions on behalf of the patient’s expressed wishes or known values.

    Medical advance directives can have limitations related to psychiatric treatment. For example, some state laws do not allow a patient’s appointed agent to authorize certain mental health interventions. Most states also allow patients to revoke their advance directives if they are able to communicate, even if their decision-making capacity is impaired from a psychiatric episode.

    Given these limitations for psychiatric patients, many states have adopted specific PAD statues. PADs allow individuals to state their mental health care preferences in advance and require that a patient be able to competently make decisions about their care to revoke their PAD.

    Currently, only 25 states have laws that allow PADs. However, most states have laws that allow patients to write advance legal instructions for their future mental health treatment, and nearly all states allow patients to appoint an agent to make at least some mental health treatment decisions on their behalf. For states that do not have PAD specific laws, a patient can still draft a PAD under their state’s more general medical advance directive laws.

    To learn more about the laws in your state, you can visit the National Resource Center on Psychiatric Advance Directives.

    A PAD goes into effect when a patient is found by their health care provider to lack decision-making capacity, for example, during periods of acute psychosis, mania, catatonia, or delirium. PADs are temporary, and once the patient regains decision-making capacity, they can resume participation in decisions about their care.

    Before writing a PAD, the first step is to think through how you would want to be treated in the event of a mental health crisis. This includes, but is not limited to:

    • Where you would want to receive care.
    • Whom you want to be notified in case of a mental health crisis.
    • If you would be okay with hospitalization, or if not, suggested alternatives to hospitalization.
    • Types of medications or medical treatments that you do or do not want.
    • The healthcare professional(s) that you want to be involved in treatment decisions.
    • Who you would want to appoint as an agent to make decisions about your mental health treatment on your behalf.

    When thinking through these decisions, it is a good idea to talk through your wishes with people who understand you and your mental illness: family, friends, health care providers, and other members of your support system. Your health care provider in particular can be very helpful in answering questions you may have about your treatment.

    An agent is a person who has been identified by a patient in their PAD to make mental health treatment decisions on the patient’s behalf if they become incapable of doing so on their own. The agent must follow the instructions in the PAD and act in accordance with the individual’s wishes, although they are able to make a range of treatment decisions, such as admission to a treatment facility, use of medication or other treatment, or changing the patient’s health care provider.

    If you are a patient considering appointing an agent to make decisions about your mental health care on your behalf in the event of a crisis, you should choose someone you trust to negotiate your care when you are unable. Your agent should be someone who:

    • Will be reachable in case of emergency;
    • You can trust to speak on your behalf;
    • Understands and is knowledgeable about your mental illness;
    • Will ensure that you get the care you want with the people you want by your side.

    You should choose your agent carefully and talk to them before you decide to make sure that they are comfortable with this responsibility and that they understand your mental illness and treatment preferences.

    Once you have decided on an agent and thought through the treatment preferences and instructions that you want to include in your PAD, you can begin the process of officially creating your PAD.

    How to create a PAD varies by state. The National Resource Center on Psychiatric Advance Directives outlines the requirements for creating a PAD in every state. Typically, creating a PAD involves filling out a state-provided form. This form generally needs to be witnessed, formally signed, and given to your physician and other mental health care providers. If your state does not have a specific form, you can refer to your state’s specific statues for creating a valid PAD without a form.

    The My Mental Health Crisis Plan mobile app, which provides a step-by-step process to create and share a PAD, is another useful resource for creating a PAD.

    Patients should ensure that their trusted loved ones are aware that they have a PAD and know where to find it. A copy should be kept in the patient’s home, where it can be easily found, and another should be kept in a safe place with other important documents. Copies of PADs should be given to patients’ agents and should be kept on file with their healthcare clinicians and at their preferred hospitals or other treatment centers.

    APA Blog: Putting a Care Plan in Place Before a Mental Health Crisis

    What are psychiatric advance directives? Where did they come from? [Excerpted from Swanson JW, 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.]

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