ALEJANDRO ROA CONTRERAS, SKYE A. MINER, MELISSA LOUISE HARRIS-GERSTEN, DANIEL SICONOLFI,
NICOLE K. EBERHART
Psychiatric Advance
Directives
A Review of the Evidence
P
sychiatric advance directives (PADs) offer individuals with psychiatric conditions the
opportunity to document their preferences for treatment and interactions during a mental
health crisis before that crisis occurs. PADs are typically promoted for persons with seri-
ous mental illness (SMI)—that is, a mental, behavioral, or emotional disorder resulting in
a functional impairment that substantially interferes with or limits major life activities (National
Institute of Mental Health, 2024). However, anyone with a history of mental illness, regardless of
severity, may benefit from this type
of advance planning. In complet-
ing a PAD, individuals are encour-
aged to identify and document
their preferences for medication
management, setting of care, points
of contact, a decisionmaking sur-
rogate, and ways of interacting with
emergency response and health
care teams (Braun et al., 2023; Gail-
lard et al., 2023). For example, indi-
viduals could indicate a preferred
hospital or mental health provider.
They also may request a hospital-
ization alternative (e.g., outpatient
care) or specific medication (or no
medication to be used), or they may
express preferences with regard to
electroconvulsive therapy or psy-
chotherapy (Gaillard et al., 2023).
A PAD template recently developed
and tested in seven California
KEY FINDINGS
■ Many U.S. states and other countries legally recognize psychiatric
advance directives (PADs).
■ Evidence shows that PADs improve autonomy in decisionmaking,
reduce coercion in crisis interventions, and lower involuntary hospi-
talization rates.
■ Barriers to the integration of PADs in crisis planning and manage-
ment include inconsistent legal recognition across states and juris-
dictions, lack of provider understanding and training, and lack of
awareness among persons with psychiatric conditions.
■ Promising practices for PAD implementation include clinician train-
ing and awareness programs, facilitating PADs with peer worker
or clinician support, and implementing clear legal mandates and
frameworks.
■ Future studies should focus on defining and measuring consistent
outcomes for clinicians, individuals who have completed a PAD,
and community members to increase the evidence regarding the
use of PADs.
■ Future implementation efforts should focus on ensuring that health
care teams are aware of and trained to understand the legal status
of PADs and how to use them within their current care environment.
Research Report
