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New research on psychiatric advance directives


Psychiatric advance directives (PADs) provide a legal means for competent individuals to refuse or consent to future mental health treatment during periods of decisional incapacity. Previous studies have shown high potential demand for PADs but low rates of completion in the United States, despite new laws authorizing PADs in over 20 states. This paper reports the results of the first randomized study of a structured, manualized intervention to facilitate completion of PADs.


A sample of 469 patients with severe mental illness were randomly assigned to a facilitated advance directive (F-PAD) session or a control group receiving written information about PADs and a referral for assistance from existing resources in the public mental health system.


Sixty-one percent of F-PAD participants completed legal advance instructions and/or authorized a proxy decision maker; 3% of control group participants completed these legal instruments. PAD instructional documents were rated by psychiatrist-raters to have highly consistent with standard standards of community practice. No participant used a PAD to refuse all treatment, though most participants refused some medications and expressed preferences for admission to specific hospitals and not others. At 1 month follow-up, F-PAD participants had significantly greater improvement in working alliance and were significantly more likely to report receiving the mental health services they believed they needed, compared to the control group. In addition other improvements were seen at 6 and 12 months in other clinical domains.


Structured facilitation of PADs may be a necessary service in order for PAD policies to be implemented and to achieve PADs' promise of providing greater self-determination and better-informed treatment decision making for persons with severe mental illness.

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Correspondence to Marvin Swartz.

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Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution 2.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Swartz, M., Swanson, J. & Elbogen, E. New research on psychiatric advance directives. BMC Psychiatry 7, S111 (2007).

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  • Mental Health
  • Mental Health Service
  • Severe Mental Illness
  • Mental Health Treatment
  • Advance Directive