RESEARCH WEEKLY: Increasing use of psychiatric advanced directives among people with SMI

By Shanti Silver

(October 4, 2023) A psychiatric advanced directive (PAD) is a way for people with severe mental illness to document their preferences for treatment in advance of an acute episode of mania or psychosis when their ability to consent to or make sound treatment decisions may be compromised. A recent article from “Voices of Bioethics” discusses how peer-support specialists can help to increase the utilization of PADs among people with SMI.  

What are psychiatric advanced directives? 

The Patient Self-Determination Act, which was passed in 1990, requires hospitals that participate in Medicare and Medicaid to ask patients if they have an “advance directive” for treatment in cases where they may be unable to consent or voice their preferences. A “Do-Not-Resuscitate” order is one example of an advanced directive.  

Currently, only 27 states allow people with mental illness to complete a psychiatric advanced directive. These PADs can allow people with SMI to designate a friend or family member to make medical decisions for them and describe their preferences for treatment during episodes of mania or psychosis. However, PADs are underutilized among people with SMI. In one study, only 4-13% of patients across several U.S. cities had a PAD. However, in that same study, 66-77% of patients expressed that they wanted to complete a PAD.  

What are barriers to completing psychiatric advanced directives? 

People who want to complete a PAD must navigate the complex healthcare system to learn about PADs and how to initiate one. This can be especially difficult to do for people with SMI who are often socially isolated and may have few people in their lives who they can trust to assist them with creating a PAD.  

Additionally, research suggests healthcare service providers may feel unequipped to help people with SMI to complete PADs. In one study, 52% of clinicians and 71% of administrators believed they would not be able to adequately assist patients with completing a PAD because they did not have enough time in their schedules. Some people with SMI may also not feel comfortable honestly expressing their preferences for treatment in front of their healthcare providers due to past negative experiences.  

Outside of healthcare providers, many people with SMI may not know who to ask for help with completing a PAD. In one study, 43% of psychiatric patients reported that they did not have someone in their life who they could trust to help them complete their PAD. This is especially notable, given that 94% of psychiatric patients report that they would be unable to complete a PAD without someone to help them. 

The role of peer-support specialists  

Because research suggests the majority of psychiatric patients want to complete PADs, it is important to consider methods for increasing the uptake of PADs among people with SMI. The author of the “Voices of Bioethics” article proposes utilizing peer-support specialists to help people with SMI to complete PADs as one such strategy. 

A peer-support specialist is someone with lived experience who is trained to help others with mental illness in the recovery process. The authors suggest that utilizing peer-support specialists to assist people with SMI with completing PADs could help people with SMI feel more comfortable exploring and honestly reporting their preferences for treatment when filling out a PAD. There may be some evidence for this, as peer-facilitated PADs have been shown to be significantly more likely to have specific instructions and guidelines for treatment than PADs that are facilitated by clinicians.  

In addition to promoting the use of peer-support specialists to assist with PADs, the author of the article also recommended creating infrastructure for a nationwide PAD database to ensure that patients’ preferences are respected even if they are receiving treatment out of state or from a new provider.  


Karasik, N. (August 2023). Protecting the autonomy of patients with severe mental illness through psychiatric advance directive peer-facilitation. Voices in Bioethics, 9. 

Shanti Silver is a research associate at Treatment Advocacy Center.

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