Psychiatric advance directives: an alternative to coercive treatment?

Psychiatric Advance Directives (PADs) are a legal means by which persons with mental illness, while competent to make healthcare decisions, may specify their preferences for treatment and may designate a surrogate decision-maker to act on their behalf in the event of an incapacitating mental health crisis. PADs have been advocated as a strategy to increase autonomy and decrease coercion in the treatment of severe psychiatric illness, but there has been little research on the actual use and effects of PADs. This article develops a conceptual model for how PADs might work, both directly and indirectly. According to the model proposed here, PADs might provide an effective tool for managing psychiatric crises but might also help to improve participation in regular outpatient treatment. This article further examines arguments for and against PADs and looks optimistically toward their use as an alternative to more coercive approaches to mental health treatment such as outpatient commitment (OPC).