[Advanced directives in psychiatry: A review of the qualitative literature, a state-of-the-art and viewpoints]

Advance statements in mental healthcare: time to close the evidence to practice gap

This article discusses advance statements in mental health care, which allow individuals with mental disorders to express their preferences for treatment during mental health crises. Despite the evidence supporting their effectiveness, their implementation in clinical practice remains limited. This article explores variations among advance statements, such as psychiatric advance directives (PADs), joint crisis plans (JCPs) and self-binding directives (SBDs), highlighting their content, development process and legal status. We outline the benefits of advance statements, including empowerment, early intervention, improved therapeutic relationships and reduced compulsory admissions. We then draw attention to the challenges that may contribute to their lack of implementation, including legal complexities, communication issues, cultural factors, potential inequities, healthcare provider knowledge, changing preferences, resource constraints, crisis responses, data privacy, family involvement, and long-term evaluation. In conclusion, advance statements offer significant benefits but require addressing these critical aspects to ensure ethical and effective use. Bridging the evidence-to-practice gap is essential, with a focus on implementation science. Integrating these tools into routine clinical practice can significantly benefit individuals with severe mental disorders and mental health systems.

Crisis plans in mental health: A scoping review

Crisis situations are frequent among people with mental health disorders. Several interventions have been developed to act in prevention, including crisis plans recognized as particularly effective in reducing coercive measures. In the literature, several models of crisis plans are proposed with similar aims and contents. Based on the methodology proposed by the Joanna Briggs Institute, a scoping review was conducted to map the state of knowledge on crisis plans in adult mental health settings. The literature search conducted on six databases (CINAHL, PubMed, Medline, EMBASE, PsychINFO and Cochrane) yielded 2435 articles. Of these, 122 full-text articles were assessed for eligibility, and 78 met the inclusion criteria. Studies were critically appraised using the Joanna Briggs Institute appraisal tools, and data were extracted by two independent reviewers. Content analysis identified a typology of crisis plans: (1) the legal crisis plan and (2) the formal crisis plan. Five modalities were identified for its completion: the sections, the moment, the completion steps, the people involved and the training of key actors. Most identified outcomes are consistent with the main purpose of the intervention, which is crisis prevention. However, the most identified outcomes focused on the service user's recovery and indicated that crisis plans could provide an opportunity to operationalize recovery in mental healthcare, thus suggesting an evolution in the aim of the intervention. Future research should further focus on the modalities of crisis plans to guide the implementation in clinical practice.

A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare

BACKGROUND

Determining the mental capacity of psychiatric patients for making healthcare related decisions is crucial in clinical practice. This meta-review of review articles comprehensively examines the current evidence on the capacity of patients with a mental illness to make medical care decisions.

METHODS

Systematic review of review articles following PRISMA recommendations. PubMed, Scopus, CINAHL and PsycInfo were electronically searched up to 31 January 2020. Free text searches and medical subject headings were combined to identify literature reviews and meta-analyses published in English, and summarising studies on the capacity of patients with serious mental illnesses to make healthcare and treatment related decisions, conducted in any clinical setting and with a quantitative synthesis of results. Publications were selected as per inclusion and exclusion criteria. The AMSTAR II tool was used to assess the quality of reviews.

RESULTS

Eleven publications were reviewed. Variability on methods across studies makes it difficult to precisely estimate the prevalence of decision-making capacity in patients with mental disorders. Nonetheless, up to three-quarters of psychiatric patients, including individuals with serious illnesses such as schizophrenia or bipolar disorder may have capacity to make medical decisions in the context of their illness. Most evidence comes from studies conducted in the hospital setting; much less information exists on the healthcare decision making capacity of mental disorder patients while in the community. Stable psychiatric and non-psychiatric patients may have a similar capacity to make healthcare related decisions. Patients with a mental illness have capacity to judge risk-reward situations and to adequately decide about the important treatment outcomes. Different symptoms may impair different domains of the decisional capacity of psychotic patients. Decisional capacity impairments in psychotic patients are temporal, identifiable, and responsive to interventions directed towards simplifying information, encouraging training and shared decision making. The publications complied satisfactorily with the AMSTAR II critical domains.

CONCLUSIONS

Whilst impairments in decision-making capacity may exist, most patients with a severe mental disorder, such as schizophrenia or bipolar disorder are able to make rational decisions about their healthcare. Best practice strategies should incorporate interventions to help mentally ill patients grow into the voluntary and safe use of medications.

Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial - DAiP study

BACKGROUND

Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France.

METHODS

A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis.

SETTING

Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews.

PARTICIPANTS

400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French.

INTERVENTIONS

The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care.

MAIN OUTCOMES AND MEASURES

The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs.

DISCUSSION

Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

How to improve clinical practice on forced medication in psychiatric practice: Suggestions from the EUNOMIA European multicentre study

BACKGROUND

The decision to adopt forced medication in psychiatric care is particularly relevant from a clinical and ethical viewpoint. The European Commission has funded the EUNOMIA study in order to develop European recommendations for good clinical practice on coercive measures, including forced medication.

METHODS

The recommendations on forced medication have been developed in 11 countries with the involvement of national clinical leaders, key-professionals and stakeholders' representatives. The national recommendations have been subsequently summarized into a European shared document.

RESULTS

Several cross-national differences exist in the use of forced medication. These differences are mainly due to legal and policy making aspects, rather than to clinical situations. In fact, countries agreed that forced medication can be allowed only if the following criteria are present: 1) a therapeutic intervention is urgently needed; 2) the voluntary intake of medications is consistently rejected; 3) the patient is not aware of his/her condition. Patients' dignity, privacy and safety shall be preserved at all times.

CONCLUSION

The results of our study show the need of developing guidelines on the use of forced medication in psychiatric practice, that should be considered as the last resort and only when other therapeutic option have failed.

Patients' attitudes towards and acceptance of coercion in psychiatry

Coercive interventions for psychiatric patients are controversial. Research on different preventive measures has increased over the last years. The present study examined patients' attitudes towards and understanding of previously experienced coercive measures as well as their preferences related to coercive measures and possible alternatives. In total, 213 patients who had experienced coercion and 51 patient controls (patients staying voluntarily on a closed ward with no coercive treatment) from three acute wards were examined via expert interviews and questionnaires in the framework of a naturalistic trial. Assessments included a new self-developed questionnaire as well as instruments measuring psychopathology. Patients who had experienced coercion differed from controls in both symptoms and insight into their illness. As expected, "noninvasive measures" (e.g., the use of a "soft room," observation in seclusion) were better accepted by patients than "invasive measures" (e.g., mechanical restraint, forced medication). Forced medication and mechanical restraint were less well accepted than involuntary hospitalization, seclusion, or video surveillance. The retrospective understanding of coercive measures increased over the course of treatment. In addition, patients rated a number of options for reducing coercion on the wards, particularly music or exercises. A large subgroup indicated they would like to discuss future admissions with the staff.

Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care

BACKGROUND

Crisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway.

DATA SOURCES

Electronic databases were searched for guidelines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, and the Health Technology Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Criminal Justice Abstracts databases. Relevant reports and reference lists of retrieved articles were scanned to identify additional studies.

STUDY SELECTION

When guidelines covered a topic comprehensively, further literature was not assessed; however, where there were gaps, systematic reviews and then primary studies were assessed in order of priority.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic reviews were critically appraised using the Risk Of Bias In Systematic reviews assessment tool, trials were assessed using the Cochrane risk-of-bias tool, studies without a control group were assessed using the National Institute for Health and Care Excellence (NICE) prognostic studies tool and qualitative studies were assessed using the Critical Appraisal Skills Programme quality assessment tool. A narrative synthesis was conducted for each stage of the care pathway structured according to the type of care model assessed. The type and range of evidence identified precluded the use of meta-analysis.

RESULTS AND LIMITATIONS

One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well.

CONCLUSIONS AND IMPLICATIONS

Most evidence was rated as low or very low quality, but this partly reflects the difficulty of conducting research into complex interventions for people in a mental health crisis and does not imply that all research was poorly conducted. However, there are currently important gaps in research for a number of stages of the crisis care pathway. Particular gaps in research on access to support before crisis point and urgent and emergency access to crisis care were found. In addition, more high-quality research is needed on the clinical effectiveness and cost-effectiveness of mental health crisis care, including effective components of inpatient care, post-discharge transitional care and Community Mental Health Teams/intensive case management teams.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014013279.

FUNDING

The National Institute for Health Research HTA programme.

Mental Health Legislation and Involuntary Hospitalization in the Republic of Macedonia

As psychiatrists, we are often obliged to provide non-consensual treatment. This institute comprises the rights of the patients with mental health disorders. The aim of this paper is to explain the contemporary mental health legislation in our country the Republic of Macedonia and the problems with the implementation of involuntary hospitalisation. This could be overcome with close cooperation between the judicial and health care system.

[Schizophrenia and informed consent to research]

CONTEXT

Informed consent to research remains a complex issue, while sometimes staying difficult to obtain, even in the general population. This problem may be maximized with patients suffering from schizophrenia.

OBJECTIVE

This paper summarizes available data in the literature about informed consent for research involving patients suffering from schizophrenia.

METHOD

Medline and Google Scholar searches were conducted using the following MESH terms: schizophrenia, informed consent and research.

RESULTS

Studies using dedicated standardized scales (e.g. MacCAT-CR) revealed a decrease in the capacity to consent of patients with schizophrenia when compared with healthy individuals. Keeping in mind that schizophrenia is an heterogeneous disorder, patients with the lowest insight as well as those with the most severe cognitive symptoms appeared more impaired in their capacity to consent. Such a poor capacity to understand and consent to trials was shown linked with alterations in decision-making. For these specific patients, interventions may be set up to increase their capacity to consent. Various strategies were proposed: enhanced consent forms, extended discussion, test/feedback method or multimedia interventions. Among them, interventions relying on communication and the growing field of information technologies (e.g. web-based tools) seem promising. Finally, associations grouping families and patients (like the French Association UNAFAM) may facilitate the involvement of patients in research programs with safer conditions.

CONCLUSION

Patients suffering from schizophrenia appear able to consent to research programs when suitable interventions are proposed. Further studies are now needed to optimize and individualize such interventions.

Use of coercive measures in mental health practice and its impact on outcome: a critical review

Although coercive measures have always been part of the psychiatric armamentarium, the ethical dilemma between the use of a "therapeutic" coercion and the loss of patients' dignity is one of the major controversial issues in mental health research and practice. The aims of the present review are to explore the existing literature on predictors of use of coercive measures and to explore the relationship between coercive measures and patient outcome. A literature search was conducted using MEDLINE, PsychyINFO, Scopus, Web of Knowledge and the Cochrane Database. In all selected papers, references were cross-checked to identify other possible eligible papers. The use of coercive measures was predicted by patients' clinical and socio-demographic features, staff characteristics and ward-related factors. Coercive measures have only a limited impact on patients' clinical and social outcome. At the current level of knowledge, coercion is still a controversial issue in mental health practice. Only few studies with a solid methodology have been carried out. Large multicenter and rigorous studies, with long-term follow-ups, are highly needed.

La personne de confiance en psychiatrie : de l’accompagnement au consentement (à l’occasion de la mise en place des directives anticipées)

La notion de personne de confiance apparaît pour la première fois dans le Code de Santé Publique dans le cadre de la loi du 4 mars 2002 (art L 1111-6 CSP) relative au droit des malades et à la qualité du système de santé, réclamée par les familles et les associations ; elle est conçue pour permettre au patient de se faire accompagner dans une démarche de soins, mais aussi comme une aide à la décision médicale ou à la participation à un protocole de recherche biomédicale. Elle a été successivement renforcée par les lois sur la bioéthique de 2004, puis sur la fin de vie en 2005, (puis en matière d’incapacité en 2007), et enfin plus récemment à l’occasion de la loi du 5 juillet 2011. Son rôle a ainsi évolué de l’accompagnement à la consultation puis au consentement. La personne de confiance doit être distinguée des « proches », de « la personne à prévenir », de « la tierce personne » et même du « tiers », alors même qu’il peut s’agir d’un parent, d’un proche ou du médecin traitant… La désignation est faite par écrit, la personne de confiance peut être différente d’une période à l’autre et même d’une situation médicale à l’autre, le patient ayant une liberté totale pour décider, et la désignation étant « révocable à tout moment ». Le législateur a voulu d’emblée que le concept en soit large, mais des éléments de confusion, de méfiance, de non-information, ont pu participer au fait qu’elle soit encore peu utilisée ou sous-utilisée, en tout cas en psychiatrie. La perspective d’adapter les procédures de directives anticipées aux modalités d’hospitalisation ou de réhospitalisation pour soins psychiatriques pourrait amener à réactualiser le rôle de la personne de confiance et à envisager une information tant des soignants que des patients et des personnes susceptibles d’être désignées.