March 15th, 2011
02:22 PM ET

Are psychiatric advance directives worthwhile?

Question asked by Claire of Rhode Island:

Do you think it is worthwhile to have a psychiatric advance directive?

For several years I have experienced bouts of depression. I've worked with my primary care doctor; psychiatrist and psychotherapist to treat it with varying degrees of success. So far, I have not needed to be hospitalized. However, as much as I hate to think about it, that may happen. I've had a medical advance directive for years and decided to add a psychiatric advance directive to it. To my surprise, my primary care doctor, psychotherapist, or psychiatrist had never heard of a PAD. They are accepted in my state. The main reason I have one is to state in writing that I am willing to have electroconvulsive therapy - my family is horrified at the thought of it. My primary care doctor and psychotherapist do think it is a good idea to have one. What is your experience with PADs - do you think they are worthwhile?

Expert answer:

Dear Claire,

I don't have much personal experience with psychiatric advance directives, because they are not well established where I practice. The question of how effective they are in general is too complex for this brief column, so let me focus instead on a topic more directly relevant to your situation, and that is whether you in particular would be likely to benefit from having a PAD.

PADs are really most appropriate for people who suffer from periods of psychosis as a result of their psychiatric illness, during which they are not competent to make decisions regarding their treatment. With a PAD, people in this situation can specify their desires for future psychiatric treatment during a period when their illness is in remission and they are, therefore, in a normal state of mind.

For example, years ago I took care of a woman with bipolar disorder who was remarkably rational when not in an episode. She was a sweet, thoughtful woman who tended toward shyness. She had complete insight into her illness and took her medications like clockwork. Unfortunately, while the medicine normalized her, it didn't protect her very well from having episodes.

Each time she became manic, she went through a brief phase in which she knew she was slipping but still had her wits about her. And then suddenly she would become hostile and enraged. She wore a trench coat 24 hours a day, slept with strangers, fought with cops and often got arrested. She became convinced that she was Eva Braun - Hitler's wife - and the Virgin Mary. And she was certain that I was part of a plot to rob her of her glory. Each time she got sick, it took a while to get her into the hospital because she lost her understanding that she needed help. How wonderful an enforceable PAD would have been for her.

Your situation, as it appears from your brief description, seems quite different. You may become depressed enough someday to need hospitalization, but it doesn't sound like you have a history of losing your insight. If you've had a number of depressive episodes and this hasn't happened yet, it's not very likely to happen. So I'm not sure that you would benefit much from a PAD, because you would most likely make the same choices if you were in hospital as you would in better times.

Having said this, I don't see any downside to getting a PAD together, other than the work involved, so if you feel strongly that you want one this also seems reasonable to me.

soundoff (19 Responses)
  1. Kate Kllingensmith

    In the NAMI (National Alliance on Mental Illness) consumer classes, there is information about a PAD. It's highly recommended. It addresses contacts, where you want to be taken–what hospital or facility, medications and dosages that work well, medications and dosages that don't work well, insurance info, and is signed by the client, advocate and primary clinican/psychiatrist. It's called an Advance Directive for Mental Health Treatment. It makes a lot of sense to me, especially the information about what medications work and don't work, because so often that's a huge issue for people entering a facility.

    March 15, 2011 at 16:14 | Report abuse | Reply
  2. Shalomit

    Re psychiatric advance directives, I was put into mental units illegally twice. I asked about the PAD's and was told I could fill in anything I wanted, but if I was on lock-down against my will, they would not even consider what I'd written no matter what my state of mind when I wrote it. I suffer from severe chronic depression, but was illegallly diagnosed w/ 4 pshcyoses and dementia when my kidneys failed causing mental status changes – the illegal part was making up a mental history on the spot because the attending did not listen to my doc re my odd reactions to ALL meds except about a half dozen. They gave me over 30 meds all for misdiagnoses and left my doc out of the loop. I was dying from the meds, and the doc didn't want that on his watch. Hence the made up psychotic history – to get me to die on someone else's watch. My doc of 30 years told the attending that I am not, nor have I ever been psychotic. I was not aware I was living for 3 weeks, but my subconscious mind was quite active – I refused the meds that were killing me. The illegal part was, of course, taking no physical conditions (of which I have too many), into account; and the main one in question was no mention of kidney probs which of course caused the mental probs. Other than those 3 weeks, I've never been in a state of mind when I was not totally 'sane' if severly depressed. The repercussions of that one major lie have destroyed anything that was left of my life. The point is that PAD's are only in play if one signs oneself into a mental unit.

    March 15, 2011 at 16:20 | Report abuse | Reply
    • maybe it is you

      Psychosis is psychosis whether organically, psychiatric or pharmacologically caused. There is a difference between "illegal" and "misdiagnosis". Yours sounds like misdiagnosis. Remember that most people who are psychotic do not have insight and ramble and rave about how they are fine and don't need treatment. If your psychiatrist diagnosed you as non-psychotic at the time and indicated this to the kidney guy, they should have come up with an appropriate treatment plan. Maybe they did and you were so out of it, it seemed inappropriate to you.

      March 24, 2011 at 20:02 | Report abuse |
  3. Dee

    That's disturbing that the staff would disregard a PAD filled out when the patient was totally competent. Anybody know how to go about getting around this? There's always the hospital ombudsperson but someone in a vulnerable state being denied their rights shouldn't be expected to know/remember to do that.

    March 15, 2011 at 16:34 | Report abuse | Reply
  4. Dr Stephanie Smith

    What an interesting question...and a thoughtful response too. Thanks for raising awareness about PAD's – not only is it a worthwhile topic, it also helps us remember that psychiatric illness should be treated no differently than physical illness.

    March 15, 2011 at 16:36 | Report abuse | Reply
  5. Stephanie

    I don't think they are helpful.

    I have never been hospitalized but feared the possibility. My disorder was not addressed by medication, I suffered horribly from the side effects, and it turned out I was one of a very large percentage of patients who simply are not helped by medication...but whose doctors persist in recommending it in some notion that it may decrease the number of episodes over time. IN my case this was not observed over time and the only effect was a severe negative impact on function and coping skills.

    I filled in an advance directive and brought it to my psychiatrist for discussion. It was detailed and outlined the many negative experiences I'd had on the medications I'd tried and my desire, should my condition ever deteriorate that far, to avoid ect and avoid all but sedation for an emergency outburst (I've never had one but I was trying to take into account what might happen).

    I was told that no facility would honor my request or the directive. The doctor herself dismissed it.

    For each medication I offered both an explanation of the negative impact it had created, the lack of effect on symptoms, and the concerns I had over long term and short term use. For a few medications I had been unwilling to attempt, I explained my reasons for rejecting these choices...all in terms of their side effect profiles and my overall medical history.

    I was quite rational at the time. It made absolutely no difference whatever.

    Later, having had a chance to read the research that supported my experience as being not at all unusual, atypical, or do to some personal lack in taking the medication as perscribed I was even more upset...as the STEP-BD study rather clearly demonstrated the dismal performance of many of these medications, and medication combinations, despite expert monitoring and the ability to ensure the patient was fully compliant.

    Too often psychiatric mediations are continued in spite of a lack of clinical effect on symptoms...and despite a deterioration in physical condition as a result of side effects. Yet, when patients note this and request not to have the burden of the side effects added to the already considerable burden of the illness itself, they are forcibly overruled.

    This is one of my greatest fears. It remains unaddressed.

    I have no objection to those for who the medications create a positive effect taking them, I think its wonderful that at least some find them a relief. But it is wrong to enforce them in cases where they do not generate a benefit, and even more wrong to dismiss the wishes of patients to not take them after they've been demonstrated to be a problem.

    I was very disillusioned to find the response to psychiatric directives to be as it is.

    March 15, 2011 at 19:05 | Report abuse | Reply


    March 16, 2011 at 01:04 | Report abuse | Reply
  7. Emily

    I have one and they're a wonderful idea for anyone who recieves mental health treatment, even just counseling. Basically you can state where you'd prefer to go for inpatient care, who your doctors are, history, meds, allergies, and other things. You don't know when a crisis will hit, but just like a living will it can help with decisions that need to be made in a hurry. It also helps you remember what you really want & decided on when you were in a better frame of mind. Make sure your PCP, any mental health professionals (psychologist, counselor, ect) family, and you all have a copy. Yes in some situations the law overrides your wishes, but it's the best way to help your wishes be known. My psychologist hopes she never has to comitt me. If it's an emergency (like attempeted suicide) I have to go to the nearest place to save my life, but if it's not she can send me to somewhere else that I prefer. I'm glad I have one.

    March 16, 2011 at 02:36 | Report abuse | Reply
  8. Joe

    Check out Doctor Breggin for a real expert opinion:


    March 16, 2011 at 06:58 | Report abuse | Reply
  9. Ituri

    And these stories are exactly why I tell NOBODY about my psychotic breaks. I know far too many people, and have read far too many horror stories, to have any confidence I'll happen to fall into the "loving" segment of treatment and care in our psychological and psychiatric systems. Far more likely, when I lose my rational self, I'd just be treated like meat and pumped full of drugs that terrify me, like it or not. At least I can sense them coming and try to prepare for them... it seems like I'm better able to treat myself, and prepare for the breaks from rationality, based on my own attempts and experiences, rather than what the so-called "professionals" are willing or able to do, so why bother.

    March 16, 2011 at 08:31 | Report abuse | Reply
    • freedom

      Ituri, remember that your freedom to remain unmedicated and psychotic ends where it negatively impacts others. When you become a threat to others, you may be committed and medicated in every attempt to regain insight and a return to proper behavior. I have been voluntary each time and both society and I benefitted. It's about being responsible.

      March 24, 2011 at 20:10 | Report abuse |
  10. meee

    I listen to all my voices

    March 16, 2011 at 22:24 | Report abuse | Reply
    • francois

      hello i a 31 yold canadian that has expeienced bad phicosis and what manipulated by evil voices telling me horipal things was this real or im i very sick

      March 17, 2011 at 06:40 | Report abuse |
  11. francois

    hello i am am ex meth/speed user and had tendency to paranoid and brought me to here voices and meen evil to me. My grandmother has a 6 sense developped and i do to.With all my recherches apparently when a user has tendency to have paranoid delusions his 6 senses become negative and the user can be manipulated by other that could reasalt to death of an heart attactt ? is th POSSIIBLLE ???

    March 17, 2011 at 06:46 | Report abuse | Reply
  12. MannyHM

    Do it ! Why ? Because having this psychiatric advanced directiive would show not only your awareness of the problem but also you desire to be helped when you are out of control. You're making the work of your health care provider much easier when your wishes are clear. I've dealt with patients who are out of control. I've to tell them that during this episode I tell them not to worry and when they get well, they'll get their freedom back.

    March 18, 2011 at 06:43 | Report abuse | Reply
  13. BigMac

    As a BiPolar Sufferer I would like to stress that I too am – 'surprisingly' – rational as in the stated case history. What is so surprising?

    March 18, 2011 at 09:22 | Report abuse | Reply
    • surprising?

      The only thing surprising is that manic depressives still misspell as "BiPolar" or "bi-polar" instead of the correct "bipolar affective disorder". I'm quite rational too and the only thing surprising is a person's reaction if I decide to tell them. How could someone so normal and educated and high-functioning be mentally ill? They're called episodes and I hide when I have them and behave better than "normal" people in between.

      March 24, 2011 at 20:17 | Report abuse |
  14. Kate

    In NH we have an additional medical advance directive that addresses dementia. The "patient" grants power of attorney to a designated person who can admit the patient to a psychiatric unit that deals with dementia patients who are at immediate risk for harm due to impaired judgement and/or disruptive behavior. My mother had the foresight to sign one and grant me power of attorney when she was well because of her experience with her own mother who had Alzheimer's and had become combative. When this happened to my mother, when she began hitting me, I signed her into a psychiatric unit specifically for elderly people with dementia. It broke my heart, but my son told me something wonderful: that the woman who signed that paper a few years ago was giving me permission to do this, that she knew it was coming and she trusted me to do the right thing for her when it happened. The staff on the psychiatric unit were wonderful, helped to get her on some medication that took away the agitation and aggressiveness, the constant wandering at night, the fighting to leave the house alone. She was not "snowed," just more herself. She was able to go home with my father for a while, until he became ill as well, and both went into nursing homes.

    March 28, 2011 at 23:21 | Report abuse | Reply
  15. Gloria Sawyer

    I have been depressed for about 40 years, not deep depression but non the less depressed.I don't really know how to have fun anymore I try to make myself but even when I do the things I used to do to have fun it's not fun and quite often I am sad, and cry alot. Several MDs have tried and non seems to help. I have been on multiple ssri's and other medications as well even b12 shots long ago it can make your life as miserable as if you were severly depressed, I get very angry and agitated about it is there help

    April 2, 2011 at 14:16 | Report abuse | Reply

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