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Why We Can’t Help Many of the Mentally Ill

The importance of psychiatric advance directives.

Key points

  • Many people in crisis simply refuse psychiatric care.
  • Patient autonomy and laws governing involuntary psychiatric hospitalization limit treatment options.
  • Psychiatric advance directives constitute a step that ensures patients’ rights to effective care.

By Joseph P. Merlino, MD, MPA, member of the Committee on Religion at the Group for the Advancement of Psychiatry

The parents of a seriously mentally ill adult child recently wrote to me, “The mental health law regime is forcing us to watch our son effectively kill himself. He is a college graduate (or would be if he completed paperwork for his degree), intelligent, talented, and, when on medication, sober, charming, funny, and a lovely person. The putative freedom to suffer from a chronic mental illness is not autonomy.” Their son, they wrote, “suffers from depression and a suspected bipolar disorder, along with the attendant drug abuse.”

Sadly, the experience of this family is not unique as frontline psychiatrists are too often unable to treat many patients in psychiatric crises resulting from mental illness or substance use.

Why can’t the mentally ill who are in crisis be taken to hospitals and be treated? Simply stated, many just say they don’t want to be treated. Their wishes must be respected because:

  1. the ethical mandate of patient autonomy
  2. laws governing involuntary psychiatric hospitalization that limit such confinement to individuals presenting as an imminent threat to self or others

This issue also affects the crisis of homelessness in the country. The Department of Housing and Urban Development counted around 582,000 Americans experiencing homelessness in 2022. About one-third of people who are chronically homeless have mental health conditions. About 50 percent have co-occurring substance use problems.

The best and most effective medical treatments available are useless to someone in the throes of psychosis when they refuse lifesaving care. Given the chronicity and severity of this problem, many tried and failed approaches to this problem need to be rethought.

Psychiatric Advance Directives

One way to address this problem is for a large-scale public campaign to educate the public, patients, and mental health providers about psychiatric advance directives, PAD, a step that actually ensures patients’ rights.

In a 2021 publication entitled Implementing Psychiatric Advance Directives: The Transmitter and Receiver Problem and the Neglected Right to Be Deemed Incapable, the authors noted, “A serious investment by clinicians and health care systems to widely implement PADs could significantly improve the treatment process for psychiatric patients who experience incapacitating crises.”

The goal is to document the patient’s wishes about treatment when they are competent, and not in crisis. For PADs to be useful and effective, the healthcare agent, acting in accordance with the patient’s wishes while competent, must prevail, even over the objections of the patient when not competent due to mental illness.

Unfortunately, psychiatrists, by and large, are not at all familiar with PADs. They are rarely used and when they are, they are more often used by patient advocates seeking to deny the most effective treatments on behalf of their clients during a mental health crisis.

PADs are medical advance directives like healthcare proxies and living wills—legally binding documents (although laws about them differ from state to state) that protect one’s rights as a patient. They indicate what one’s treatment choices are in advance of when one might not be able to make them oneself due to incapacitating illness and include the use of psychiatric medication and hospitalization.

The Problem

Psychiatrists working in emergency settings all too often are asked to evaluate people brought in by families or police in the midst of having a psychotic episode but who refuse care. If they are not thought to be an immediate danger to themselves or others, they are discharged to live on the street and to fare as best they can to survive.

Yet, many of these people would do so much better if they were effectively treated, and potentially able to resume their lives with family in the community, as noted above. For example, patients diagnosed with bipolar disorder. when stable and receiving treatment, can be gainfully employed and live with or near family members. However, when in the midst of a manic episode, they can lose their jobs and deplete their family’s savings. Most significantly, when severely depressed, they may take their own lives, leaving families behind to grieve and mourn.

Why have PADs not taken hold like their medical counterparts? There are several implementation problems involved in the successful use of PADs, many having to do with communication and practice.

A concerted push to educate mental health care providers could go a long way towards making the PAD as intrinsic to healthcare as the medical healthcare proxy and living will are. Some steps that can be quickly and easily taken include teaching about the use of PADs in psychiatric residency and other mental health professional training programs. Additional steps could include patient education about PADs during psychiatric hospital discharge planning and during outpatient mental health treatment. Healthcare organizations can include questions and information about PADs just as with other kinds of medical advance directives.

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