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A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams.We examined ACT clients' attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference.Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment.PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

Social workers in mental health settings struggle to support the principle of autonomy while weighing the need to directively intervene when there is a risk of harm or when clients are nonadherent to treatment. However, our understanding of this tension is incomplete. We therefore engaged in a survey of 193 social workers in North Carolina regarding attitudes toward autonomy and directive interventions, and examined correlates of these attitudes. Findings revealed that respondents having a client with a psychiatric advance directive were significantly more supportive of client autonomy. Respondents who were licensed, working in an inpatient setting, or had briefer client contacts were more likely to endorse the need for directive interventions, and those working in the public sector reported more use of warnings to improve adherence. Implications for practice, training, and research are discussed.

Involuntary psychiatric treatment is sometimes necessary and beneficial, but may also exert negative effects. The impact of involuntary commitment on subsequent mental health treatment experience is poorly understood. We examined whether history of involuntary commitment was associated with current perceptions of coercion in a sample of voluntarily hospitalized veterans (N = 205). In adjusted analyses, perceived coercion during the voluntary admission was significantly associated with prior history of involuntary commitment (Rate Ratio = 1.60, p = .05). Perceived coercion was also higher among participants who were married/cohabiting (Rate Ratio = 1.83, p = .01) and among those with greater functional impairment (Rate Ratio = 0.97, p = .04). Although frequently unavoidable, the current results underscore the potential negative effects of coercive practices such as involuntary commitment, and support the importance of policies that aim to minimize coercive treatment experiences among psychiatric patients.

The cost-effectiveness component of the 18-month CATIE trial of schizophrenia pharmacotherapy (n = 1460) showed that the first-generation antipsychotic perphenazine was US$300-600 per month less expensive than each of four second-generation antipsychotics, and no less effective across multiple measures. We consider whether or not each of eight potential methodological limitations could weaken this conclusion: follow-up rates, study duration, sample characteristics, the choice of outcome measures, exclusion of patients with tardive dyskinesia from assignment to perphenazine, choice of study drugs and doses, reliance on intention-to-treat analysis, and differences in prestudy treatment. We conclude that results of CATIE are robust to these limitations. Perphenazine seems to have been a more representative choice for first-generation antipsychotic comparison treatment than haloperidol.

Limited research has examined patients' preferences for psychiatric advance directives (PADs). This study examines the preferences and interest in PADs among patients with severe mental illness. Participants in a randomized controlled trial of PAD facilitation versus usual care were interviewed about their preferences and interest in PADs. Preferences scores were estimated and compared among patients wishing to complete types of PADs. The large majority of participants indicating an interest in a PAD that included a healthcare power of attorney gave greatest importance to enabling surrogate decision making and continuity of care during crises, a minority who expressed interest in a stand-alone advance instruction for mental health treatment or no PAD at all gave highest priority to avoiding unwanted treatment. Persons with severe mental illness have diverse interests in PADs. Most patients give high priority to improving surrogate decision making and continuity of care with PADs.

Psychiatric advance directives (PADs) document a patient's advance instructions (AIs) for treatment and/or designation of a potential proxy decision maker. Approximately 50% of a total of N=167 U.S. psychiatrists who completed a mail survey of their attitudes and views regarding PADs had a favorable opinion of a law authorizing AIs, whereas two-thirds of psychiatrists endorsed proxy decision making legislation. However, 42% perceived important barriers in the service system that would prevent effective implementation of PADs, while 30% considered clinical factors to be important barriers to implementation. Psychiatrists who are correctly apprised of applicable state mental health law are generally more supportive of PADs; they may be more willing to support PADs if they are educated about key aspects of PAD legislation.

Policies to leverage adherence with community-based mental health treatment have become widespread; however, little research exists on the attitudes of persons with psychiatric disorders regarding such leverage. This study examines the appraisals of 1,011 persons with psychiatric disorders regarding the fairness and effectiveness of leverage. A majority of consumers perceives leverage to be both fair and effective; these perceptions are highly correlated. Multivariate models suggest that perceived coercion and insight into illness are associated with both outcomes while number of hospitalizations, years in treatment, and appointment reminders are associated with either outcome. However, consumers with a psychotic diagnosis and high barriers to care view leverage as unfair when controlling for effectiveness. Consumers who experience less coercion and have better insight believe that they benefit from formal and informal sanctions to adhere to treatment. However, perceived barriers to care impact the evalua...

Psychiatric Advance Directives are relatively new legal tools that allow competent persons to consent or refuse mental health treatment and designate a proxy decision maker in advance of a mental health crisis, during which they may lose capacity to make healthcare decisions. Psychiatric Advance Directives hold the promise of improving care during mental health crises but also raise a number of clinical, legal, and ethical issues. This article provides an illustration and critical analysis of issues raised by Psychiatric Advance Directives.

Although the use of representative payees has proliferated in the past decade, little is known about whether clinicians or family members of people with mental illness use their control of clients' money to leverage treatment adherence or whether persons with psychiatric disabilities perceive that if they are noncompliant, their money will be withheld. The purpose of this study was to examine clinical and demographic variables associated with perceived financial coercion and warnings involving control of money in the context of mental health services. 258 involuntarily admitted inpatients with severe mental illness were followed for one year and interviewed, as were their clinicians and family members. Results showed that nearly 30% of participants perceived financial coercion whereas a smaller fraction of participants' clinicians and family members reported giving money warnings. However, some factors, including ethnicity and being subject to other legal mechanisms, predicted both—actual warnings and per...

Psychiatric advance directives (PADs) allow competent persons to request or refuse specific types of treatment and designate a proxy decisionmaker in advance of a mental health crisis when they may lose capacity to make reliable healthcare decisions. A survey of attitudes and opinions about PADs was conducted in three stakeholder groups with a sample of 104 persons with schizophrenia and related disorders, 83 family members of persons with severe mental illness (SMI), and 85 clinicians who treat persons with severe mental illness. Among the sample of persons treated for schizophrenia, only 7 (6.80%) reported having a PAD, but 62 (67.39%) reported that they would complete a PAD if provided assistance. Respondents in all three stakeholder groups largely expressed great interest in PADs, but indicated that they had little or no experience with these new legal instruments. Patients, family members, and clinicians differed substantially in their opinions about the goals of PADs, the likely effectiveness of the...

Chlorpromazine, which was discovered in 1952, has an exhaustively characterized efficacy/safety profile comprising serious limitations: effectiveness in the field failing to match efficacy in trials, residual symptoms in 50% of patients, a 20% relapse rate in compliant patients, and worrisome extrapyramidal side effects, including tardive dyskinesia in 5% per year. Second-generation "atypical" antipsychotics bypass these effects by having less affinity for the dopamine D(2) receptor and affinities for other neuroreceptors. Clozapine, the lead atypical antipsychotic, was followed in the mid 1990s by risperidone, olanzapine, and quetiapine, which now account for over half of new antipsychotic prescriptions in North America, The debate over their relative efficacy involves the potential well-being of millions of schizophrenics and billions of dollars. Atypical antipsychotics are considerably more expensive; evidence for their superiority is highly variable and often inadequate, largely confined to short-term regulatory studies. Their effects on long-term outcome (particularly negative symptoms), relapse prevention, social and vocational functioning, suicide prevention and quality of life, and family and caregiver burden are largely unknown. The National institute of Mental Health's Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) project is a combined efficacy-effectiveness trial that aims to answer these questions in a broad range of patients with schizophrenia and Alzheimer's disease.

This paper examines links between violent behavior, type and severity of psychopathology, substance abuse comorbidity, and community mental health treatment, using matched data from two surveys: the National Institute of Mental Health Epidemiologic Catchment Area project and the Triangle Mental Health Survey (a North Carolina study of adults with severe and persistent mental illness). Multivariate logistic regression analysis was used to model the risk of violent acts attributable to three domains of independent variables: sociodemographic characteristics, clinical diagnoses and symptomatology, and mental health services utilization. Findings include: (1) Symptom severity was significantly greater in the clinically-selected sample than in the community survey of respondents with comparable diagnoses who self-reported using mental health services; (2) Violence risk was related to psychoticism/agitation in a curvilinear form; (3) In a multivariable model, violence was significantly associated with substance abuse comorbidity, particular psychotic symptoms (perceived threat and loss of internal cognitive controls), and absence of recent contact with a community mental health provider; (4) The relationship between lack of treatment and higher odds of violence was less pronounced among respondents with substance abuse comorbidity; (5) When clinical and services-use variables were taken into account, sociodemographic predictors were not significantly related to violence.