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. 2009 Jan 21;2009(1):CD005963.
doi: 10.1002/14651858.CD005963.pub2.

Advance treatment directives for people with severe mental illness

Leslie Anne Campbell  1 , Steve R Kisely
Affiliations

Advance treatment directives for people with severe mental illness

Leslie Anne Campbell et al. Cochrane Database Syst Rev. .

Abstract

Background: An advance directive is a document specifying a person's preferences for treatment, should he or she lose capacity to make such decisions in the future. They have been used in end-of-life settings to direct care but should be well suited to the mental health setting.

Objectives: To examine the effects of advance treatment directives for people with severe mental illness.

Search strategy: We searched the Cochrane Schizophrenia Group's Register (February 2008), the Cochrane Library (Issue 1 2008), BIOSIS (1985 to February 2008), CINAHL (1982 to February 2008), EMBASE (1980 to February 2008), MEDLINE (1966 to February 2008), PsycINFO (1872 to February 2008), as well as SCISEARCH and Google - Internet search engine (February 2008). We inspected relevant references and contacted first authors of included studies.

Selection criteria: We included all randomised controlled trials (RCTs), involving adults with severe mental illness, comparing any form of advance directive with standard care for health service and clinical outcomes.

Data collection and analysis: We extracted data independently. For homogenous dichotomous data we calculated fixed-effect relative risk (RR) and 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD) and their 95% confidence interval again using a fixed-effect model.

Main results: We were able to include two trials involving 321 people with severe mental illnesses. There was no significant difference in hospital admission (n=160, 1 RCT, RR 0.69 0.5 to 1.0), or number of psychiatric outpatient attendances between participants given advanced treatment directives or usual care. Similarly, no significant differences were found for compliance with treatment, self harm or number of arrests. Participants given advanced treatment directives needed less use of social workers time (n=160, 1 RCT, WMD -106.00 CI -156.2 to -55.8) than the usual care group, and violent acts were also lower in the advanced directives group (n=160, 1 RCT, RR 0.27 CI 0.1 to 0.9, NNT 8 CI 6 to 92). The number of people leaving the study early were not different between groups (n=321, 2 RCTs, RR 0.92 CI 0.6 to 1.6).

Authors' conclusions: There are too few data available to make definitive recommendations. More intensive forms of advance directive appear to show promise, but currently practice must be guided by evidence other than that derived from randomised trials. More trials are indicated to determine whether higher intensity interventions, such as joint crisis planning, have an effect on outcomes of clinical relevance.

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Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 1 Death.
1.2
1.2. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 2 Overall psychiatric admissions.
1.3
1.3. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 3 Involuntary psychiatric admissions within 15 months.
1.4
1.4. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 4 Voluntary psychiatric admissions within 15 months.
1.5
1.5. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 5 Involuntary bed days.
1.6
1.6. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 6 Outpatient contacts.
1.7
1.7. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 7 Compliance with mental health treatment.
1.8
1.8. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 8 Self harm.
1.9
1.9. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 9 Violence.
1.10
1.10. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 10 Criminal justice contacts.
1.11
1.11. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 11 Social services.
1.12
1.12. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 12 Other health services.
1.13
1.13. Analysis
Comparison 1 ADVANCE DIRECTIVES versus USUAL CARE, Outcome 13 Leaving the study early.
See this image and copyright information in PMC

Update of

References

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References to studies awaiting assessment

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