Conference Coverage

Advance directives for psychiatric care reduce compulsory admissions



Providing peer or community health workers to help psychiatric patients complete psychiatric advance directives (PAD) – which 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 with 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 in JAMA Psychiatry.

However, Dr. 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 health care, 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 Dr. 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 and be supported in drafting the document and in sharing it with health care 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 versus 41 years (P = .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 < .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 completed 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% versus 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 versus 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, or quality of life.


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