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J Am Acad Psychiatry Law. 2006;34(1):43-57.

Psychiatric advance directives among public mental health consumers in five U.S. cities: prevalence, demand, and correlates.

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Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3071, Brightleaf Square Suite 23-A, Durham, NC 27710, USA.


Psychiatric advance directives (PADs) are legal instruments that allow competent persons to document their preferences regarding future mental health treatment and to designate a surrogate decisionmaker in the event they lose capacity to make reliable treatment decisions during an acute episode of psychiatric illness. This study reports the findings of a survey of 1,011 psychiatric outpatients in five U.S. cities about their interest in, and completion of, PADs. Across the sites, only 4 to 13 percent of participants had completed a PAD; however, between 66 and 77 percent reported wanting to complete one if given assistance. Significantly higher demand for PADs was found among participants who were female; were nonwhite; had a history of self-harm, arrest, and decreased personal autonomy; and those who felt pressured to take medication. Actual completion of PADs was more likely among participants with higher insight, those reporting leverage by a representative payee, and those who felt external pressure to keep outpatient appointments for mental health treatment.

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