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Are psychiatric advance directives worthwhile?

Asked by Claire, Rhode Island

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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?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

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.

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