Comments on "How Do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study from India".

Sir,

This correspondence is made in reference to the original article “How do our patients respond to the concept of psychiatric advance directives? An exploratory study from India” by Tekkalaki et al.[1] The paper explored how willing the patients are to make advance directives (AD), and given a chance, what treatment options/setting they would like to opt or refuse. The study is another step forward in understanding the response of patients in Indian settings to the AD.

However, the study did not try to explore the attitude of patients or their family members towards the concept of the AD. The questions regarding AD were limited and in the form of simple yes/no questions. If open-ended questions were used instead, it would have helped to arrive at themes and other concerns related to the preparation of AD. The role of the caregiver and their possible influence in making AD too could have been explored. Since India is a developing country, the additional challenges faced, like the effect of the rural/urban background, availability of resources, feasibility, likely benefits/hardships and difference to the care of patients in future due to ADs, need further insight. As a part of the AD, a person can also nominate a representative to make decisions in case of illness and lack of capacity, a factor which has not been discussed in the current study. Authors have used a relatively simple tool, Clinical Global Impression Scale, for assessing the clinical status of patients. Authors could have used standard structured scales like Positive and Negative Syndrome Scale, Young Mania Rating Scale, Hamilton Depression Rating Scale, etc., to achieve a better judgement about the status of symptoms in patients with schizophrenia or bipolar disorder.

The authors have discussed a few limitations of their paper. We would like to elaborate further on two of them. First, the capacity to make AD was not assessed in this study, which is an important issue and was addressed in a previous Indian study on the AD.[2] Clause (d) of sub-section (2) of section 11 of Mental Healthcare Act, 2017 clearly mentions that Mental Health Review Board could cancel the AD if it is found that the person did not have the capacity to make a decision relating to his mental health or treatment when such AD was made.[3] Therefore, any research about AD would be considered incomplete if due attention is not paid to assessment of capacity to make an AD. Second, the assessment of insight and cognitive status was not done. Research has shown that, both in schizophrenia and bipolar disorder, insight and cognitive status are closely interlinked.[45] To be able to make a reasonable AD, a person who has already suffered or is suffering from a psychiatric illness must have insight into his/her illness; its future implications, course, and prognosis; knowledge about the need for treatment, available treatment options and their potential benefits/adverse reactions, and implications of selecting/refusing certain treatment options. The poor cognitive profile would also hamper one's ability to grasp information about illness/treatment. The AD made under such state would carry a high likelihood of alteration/cancellation by competent authorities.

The researchers have made a sincere effort in understanding the requirements of patients. Extending this pilot study keeping the above-mentioned points in mind shall help us in gaining a better understanding of patients’ perspective about ADs and guiding them to achieve the maximum possible benefit of ADs.

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Conflicts of interest

There are no conflicts of interest.