Va. Studies Directives Giving the Mentally Ill A Say in Their Care

By Chris L. Jenkins
Washington Post Staff Writer
Monday, September 10, 2007

Yvonne Smith has had a pair of mental illnesses diagnosed over the years, but it wasn't until a severe psychotic episode landed her in a psychiatric ward that she came to a sober realization: Although her family and friends had long been supportive of her struggles with bipolar disorder, they couldn't always know what to do when she was incapacitated.

So, soon after she left the hospital, she wrote some simple instructions with a psychiatrist and an attorney on how to care for her if she had a severe episode again: She was to be taken to Georgetown University Hospital if possible; she was not to receive antipsychotic drugs through a needle; and electroconvulsive therapy, known as ECT, was prohibited.

"My friends and family know the symptoms of my condition, but they don't always know about recovery," said Smith, 55, a District resident. "I got to a point where I wanted the things that work best for me to be written down, so that if I was ever in the hospital again, there would be clear instructions."

Smith's wishes are embedded in a legal document known as a psychiatric advance directive, which is designed to instruct health-care professionals, family members and friends about how mentally ill patients are to be cared for when they are incapacitated.

Prepared when a patient is lucid, the documents often give instructions on what medications or treatments to use, what hospital is preferred and, sometimes, instructions on how the patient should be engaged by mental health professionals. The advance directives are designed to give patients some control over their care.

But the directives have also raised concerns, because they're not always binding. In some states the instructions can be revoked by someone going through a psychotic crisis, and in some cases doctors can override a patient's wishes. In addition, some say the documents promote inequality and discrimination by highlighting a mental illness apart from broader health issues, which only serves to stigmatize those with schizophrenia and other severe disorders.

The disagreements illustrate the difficulty of trying to expand rights to those with severe mental illness while also providing proper care in emergency situations.

As Virginia considers comprehensive revisions to its mental health system this year, one of the issues that lawmakers, mental health professionals and state officials have discussed is whether to implement the little-known directives, which are available in Maryland and the District. As in all states, such mental health-care instructions in Virginia can be passed on to loved ones through health-care proxies, which can give family members the ability to instruct doctors about the care of a mentally ill person. But the state allows people to make future health-care instructions through advance directives only in end-of-life situations.

Supporters of advance directives say they give those prone to episodes of psychosis an opportunity to control their treatments during mental breakdowns. Some researchers and psychiatrists also say advance directives can help doctors and their patients talk honestly about what happens during psychotic episodes, increasing the possibility that mentally ill patients will gain insight into their conditions.

Like a living will, most advance directive documents require two witnesses and notarization. "The psychiatric advance directives are based on experiences people have had many times over," said Eric Elbogen, a forensic psychologist at the University of North Carolina School of Medicine, who has done research on the documents. "It can help determine what medications work best or which ones don't work at all, because it's based on past, real-life experiences."

About 13 million Americans struggle with serious mental illnesses, including bipolar disorder, schizophrenia and severe clinical depression. About two dozen states have psychiatric advance directive statutes that specifically allow for those with mental illness to develop treatment plans. Supporters said that developing a separate psychiatric advance directive law helps promote their usage and can encourage people to take control of their care.

That was the case for Marcia Anders of Durham, N.C., who was recently overcome with the gale of despair she recognized all too well as a psychotic breakdown -- the kind that in the past had landed her in the hospital for weeks at a time.

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