Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Pacific O (Hyatt Regency San Francisco)

Psychiatric Advance Directives: What Do (and Should) Social Workers Know?

Anna M. Scheyett, MSW, University of North Carolina at Chapel Hill, Mimi Misung Kim, PhD, Duke University, Jeffrey Swanson, PhD, Duke University, Marvin Schwartz, MD, Duke University, Eric Elbogen, PhD, Duke University, Richard Van Dorn, PhD, Duke University, and Joelle C. Ferron, MSW, University of North Carolina at Chapel Hill.

Purpose: Psychiatric Advance Directives (PADs) are legal documents allowing competent individuals with mental illness to express their wishes for psychiatric care at a future time when they may no longer be able to do so. PADs are intended to enhance autonomy when clients are most vulnerable—when needing treatment, but unable to voice their wishes because of illness (Joshi, 2003). Despite their potential utility, PADs are infrequently used (Swanson, Swartz, Ferron, Elbogen, & Van Dorn, in press). Using data from an exploratory survey, the aims of this study were to examine: 1) social workers' familiarity with PADs; 2) their sources of information regarding PADs; 3) their support for PAD; 4) their utilization of PADs, and 5) consider implications of findings for practice.

Methods: This investigation analyzed responses from a survey of North Carolina mental health social work practitioners (N=193). Survey questions explored participants' familiarity with PADs, sources of PAD information, support for PADs, and PAD utilization. Descriptive statistical analyses summarized sample responses. To explore the relationship between participant characteristics and familiarity with and support for PADs, first bivariate analyses, then multivariate analyses using logistic regression analysis with stepwise inclusion and exclusion at p<.20 level were completed. Results: Only a third of respondents reported being very/somewhat familiar with PADs (n=64). Mean time since learning about PADs was 1.77 years (SD=1.9), and primary information sources were colleagues (n=50; 47.2%) and continuing education (n=42; 39.6%). Though 38.3% (n=74) reported support for PADs, only 11.4% (n=22) reported having had a client with a PAD. Logistic regression analyses (controlling for age, race, gender) revealed significant associations between PAD familiarity and having >10% psychotic clients on one's caseload (OR=4.76; 95%CI 2.00, 11.36), working in an ER (OR=3.30; 95%CI 1.33, 8.19), and an interaction effect between years of mental health experience and hospital work, with working in a hospital and having >7 years of experience significantly associated with PAD familiarity. (OR=5.54; 95%CI1.15, 26.66). Having >10% psychotic clients on one's caseload and having >7 years experience were significantly associated with PAD support (OR=2.57; 95%CI 1.34, 4.95; OR=1.96; 95%CI 1.04, 3.73, respectively).

Practice Implications: Findings suggests that most social workers are in need of education regarding PADs. Practitioners in hospital and crisis settings were most familiar with PADs; these are settings where PADs may be invoked, but not where one would expect them to be created. Therefore social workers in non-crisis, non-inpatient settings should be targeted for PAD education so they may assist clients in PAD creation. Second, significantly lower PAD familiarity and support were seen in social workers working primarily with non-psychotic clients. Many non-psychotic (e.g. depressed) clients could benefit from PADs; social workers providing services to clients with non-psychotic disorders should also be targeted for PAD education.

Joshi, K. (2003). Psychiatric advance directives. Journal of Psychiatric Practice, 9(4), 303-306. Swanson, J., Swartz, M., Ferron, J., Elbogen, E., & Van Dorn, R. (in press). Psychiatric advance directives: Prevalence, demand, and correlates among mental health consumers in five U.S. cities. Journal of the American Academy of Psychiatry and Law.