Using Psychiatric Advance Directives with Jail-Involved Individuals with Serious Mental Illnesses: Choice Within Coercion?

Purpose: Individuals with serious mental illnesses (SMI) have high incarceration rates (Theriot & Segal, 2005). Jails face multiple challenges when SMI individuals are incarcerated, often having no knowledge of individuals' medications and being unable to communicate with providers because of confidentiality restrictions. (Lamberti & Weisman, 2004). SMI individuals may, as a result, not receive preferred/effective care while incarcerated. Psychiatric Advance Directives (PADs) are legal documents allowing SMI individuals to document preferences for psychiatric treatment during crisis times when they may no longer be able to communicate choices. PADs may also be used as a record of treatment and limited waiver of confidentiality (Joshi, 2003). Using data from a survey of jail administrators, this study examines: 1) jail administrators' familiarity with PADs; and 2) their views of PAD utility for SMI individuals in jails.

Methods: Study data were from a larger phone survey of all 93 North Carolina jail administrators regarding jails and SMI. Eighty participated (response=87%); 78% of respondents were overall jail administrators, 22% were jail medical administrators. Jail daily census ranged from 8-2700 (mean=195,SD=332.4, median=120). To ensure consistent understanding, respondents were first read a standard PAD description. Then respondents were asked about prior familiarity with PADs, asked to rate their support of PADs on a 5-point scale (strongly agree-strongly disagree), and explain their response via open-ended question. Descriptive statistical analyses summarized responses; relationships between respondent characteristics and PAD support were examined using chi-square tests. Qualitative analyses were completed on explanatory responses.

Results: Only 8(10%) respondents reported familiarity with PADs. Overall, respondents were supportive of PADs; when asked whether PADs were a good idea, 58(72.5%) responded Strongly Agree or Agree. Chi-square tests showed respondents from smaller jails (<120) were significantly more likely to support PADs (χ2 =3.94, p=.04). Overall jail administrators' PAD support trended toward being significantly higher than medical administrators' (χ2=3.66, p=.056). Qualitative analyses revealed several themes. PADs were seen as positive because they gave jails needed information and “a course of action”, helped SMI individuals get care, and were “empowering.” They were seen as negative because of jail limitations (jails don't provide “lots of choice”, have limited formularies) and belief that SMI individuals were never competent to create PADs because of co-morbid addiction.

Conclusions and Implications: Findings suggests PADs may be useful intervention for some jail-involved SMI individuals, as a way to both provide jails with needed information about treatment and providers and facilitate individuals receiving preferred care. Jail administrators may be open to this intervention, particularly in smaller, less well-resourced jails. However, regulatory and other restrictions in jails may limit PAD utility. Additional research examining PADs as an intervention to enhance choice and effective care for justice-involved SMI individuals is needed.

Joshi, K. (2003). Psychiatric advance directives. Journal of Psychiatric Practice, 9(4), 303-306.

Lamberti, J., & Weisman, R. (2004). Persons with severe mental disorders in the criminal justice system. Psychiatric Quarterly, 75, 151-164.

Theriot, M., & Segal, S. (2005). Involvement with the criminal justice system among new clients at outpatient mental health agencies. Psychiatric Services, 56, 179-185.