Advance treatment directives for people with severe mental illness

 

Abstract

Background

An advance directive is a document specifying a person's preferences for treatment, should he or she lose capacity to make such decisions in the future. They have been used in end-of-life settings to direct care but should be well suited to the mental health setting.

Objectives

To examine the effects of advance treatment directives for people with severe mental illness.

Search methods

We searched the Cochrane Schizophrenia Group's Register (February 2008), the Cochrane Library (Issue 1 2008), BIOSIS (1985 to February 2008), CINAHL (1982 to February 2008), EMBASE (1980 to February 2008), MEDLINE (1966 to February 2008), PsycINFO (1872 to February 2008), as well as SCISEARCH and Google - Internet search engine (February 2008). We inspected relevant references and contacted first authors of included studies.

Selection criteria

We included all randomised controlled trials (RCTs), involving adults with severe mental illness, comparing any form of advance directive with standard care for health service and clinical outcomes.

Data collection and analysis

We extracted data independently. For homogenous dichotomous data we calculated fixed-effect relative risk (RR) and 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD) and their 95% confidence interval again using a fixed-effect model.

Main results

We were able to include two trials involving 321 people with severe mental illnesses. There was no significant difference in hospital admission (n=160, 1 RCT, RR 0.69 0.5 to 1.0), or number of psychiatric outpatient attendances between participants given advanced treatment directives or usual care. Similarly, no significant differences were found for compliance with treatment, self harm or number of arrests. Participants given advanced treatment directives needed less use of social workers time (n=160, 1 RCT, WMD -106.00 CI -156.2 to -55.8) than the usual care group, and violent acts were also lower in the advanced directives group (n=160, 1 RCT, RR 0.27 CI 0.1 to 0.9, NNT 8 CI 6 to 92). The number of people leaving the study early were not different between groups (n=321, 2 RCTs, RR 0.92 CI 0.6 to 1.6).

Authors' conclusions

There are too few data available to make definitive recommendations. More intensive forms of advance directive appear to show promise, but currently practice must be guided by evidence other than that derived from randomised trials. More trials are indicated to determine whether higher intensity interventions, such as joint crisis planning, have an effect on outcomes of clinical relevance.

 

Plain language summary

Advance treatment directives for people with severe mental illness

An advance treatment directive is a document that specifies a person’s future preferences for treatment, should he or she lose the mental ability to make treatment decisions (lose capacity). They have traditionally been used to stipulate treatment in end-of-life situations. However, people with mental health problems can also have periods where they are unable to make treatment decisions, and an advance statement could help with choosing suitable medication, saying who should look after children and specifying choices in other areas of their life and treatment.

This review looks at whether having an advance statement leads to less hospitalisation (either voluntary or involuntary), less contact with mental health services and whether there is an improvement in general functioning. Two studies were found, involving 321 people. Both took place in England. One trial involved the person concerned making a joint crisis plan in collaboration with the psychiatrist, care coordinator and project worker (high intensity), while the other required filling in a booklet called ‘preferences for care’ (low intensity). Both studies were compared to the usual care in the area concerned.

Since the interventions were quite different, and not all outcomes were measured by both studies, it is quite difficult to compare the trials. Those who filled in the booklet showed no decrease in admission to hospital (voluntary or involuntary) or contact with out-patient services, when compared to usual care. The high intensity group showed no differences in voluntary admissions compared to those in usual care, but were less likely to be hospitalised involuntarily, or assessed under the Mental Health Act. They were also less likely to be violent. There was no difference in use of psychiatric out-patient services by those in the intervention groups. These are small studies and more research is needed, but it is suggested that using an advance treatment directive could be an alternative to community treatment orders.

(Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org)

 

摘要

背景

嚴重精神疾病病人的進階治療指引

進階治療指引是特別述明患者治療偏好和他將來是否沒有能力決定治療的文件.已經在安寧病房使用未指明目的的,不過也應使用在精神醫療院所

目標

檢視進階治療指引對嚴重精神疾病病人的療效

搜尋策略

搜尋Cochrane Schizophrenia Group's Register (2008年二月), the Cochrane Library (2008年卷1), BIOSIS (1985年 – 2008年二月), CINAHL (1982 – 2008年二月), EMBASE (1980 – 2008年二月), MEDLINE (1966 – 2008年二月), PsycINFO (1872 – 2008年二月), 和SCISEARCH及 Google(網路搜尋引擎,2008年二月).也尋找相關的文獻和連絡納入研究的第一作者

選擇標準

我們納入所有關於嚴重精神疾病成年病人的隨機對照試驗,比較任何形式進階治療指引和標準照護療法的健康服務和臨床結果.

資料收集與分析

我們獨立擷取資料.計算意圖治療患者的同質二元數據的固定效果相對危險(RR)和95%信賴區間(CI).使用固定效果模式,計算連續資料的加權平均差異和95%信賴區間.

主要結論

我們納入兩個試驗,共321位嚴重精神疾病的病人. 使用進階治療指引患者和一般照護相比,入院或精神門診的出席次數沒有顯著差異(樣本數為160, 一個隨機對照試驗, RR為 0.69 CI為0.5 – 1.0).治療遵醫矚性,傷害自己或被逮捕次數也沒有顯著差異. 使用進階治療指引患者與一般的照護團體相比,需要較少的社工時數(樣本數為160, 一個隨機對照試驗, 加權平均差 −106.00 CI為 −156.2至 −55.8)和暴力行為(樣本數為160,一個隨機對照試驗, RR 0.27 CI為 0.1 – 0.9, 益一需治數(NNT)為 8 CI為 6 – 92).提早退出試驗的人數在兩組間沒有差異(樣本數為321, 兩個隨機對照試驗, RR為 0.92 CI為 0.6 – 1.6).

作者結論

可用的資料太少不能做出確定的建議.更詳細的進階治療指引似乎有效,但需要隨機試驗以外的證據以修正現行的作法.更多的試驗才能指出是否能決定如整合危機計劃這種高強度的介入對臨床相關的結果有效.

翻譯人

本摘要由成功大學附設醫院尹子真翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

嚴重精神疾病病人的進階治療指引: 使用系統性回顧現有的隨機對照試驗,檢視進階治療指引對嚴重精神疾病病人的療效.我們只找到兩個相關的試驗.這沒提供什麼證據證明進階治療指引對自願/非自願精神科入院,住院天數,遵醫矚性, 傷害自己,暴力行為,之前在精神健康衛生法案(Mental Health Act)下的評估或使用醫療服務. 整合危機計劃這種高強度的介入,比起低強度的進階治療指引似乎對減少非自願入願有效,但沒有足夠的證據評估他們的效益.