Advance Directives for Persons With Serious Mental Illness

To the Editor: The May issue of Psychiatric Services includes three articles focusing on the clinical utility of medical and psychiatric advance directives for persons with serious mental illness (1,2,3). In the absence of nationally accepted clear guidelines, the topic is complex and intriguing. The onset of two major psychiatric illnesses—bipolar disorder and schizophrenia—occurs in late adolescence and early adulthood. It is important to discuss advance directives with patients who have these illnesses soon after the onset of illness, at an earlier age than people in the general population typically begin to think about advance directives.

The need to discuss this topic early after illness onset has become clearer in light of recent research findings showing that each psychotic exacerbation among patients with schizophrenia and each mood episode among patients with bipolar disorder lead to subtle brain damage, as evidenced by periventricular white matter opacities that can be seen with magnetic resonance imaging and cognitive deficits in executive functions and deficits in psychosocial functioning that are revealed by neurocognitive testing and other assessments. Frontal lobe deficits have been found to persist even in states of relative stability among patients with schizophrenia and in euthymic states of patients with bipolar disorder (4,5). It has been difficult to disentangle the role and contribution of stabilizing psychotropic medications with regard to cognitive difficulties. Furthermore, subtle subsyndromal mood symptoms of depression or hypomania may not be gauged by primary care doctors but may affect the decision-making capacity of some patients. Therefore, use of one or more screening instruments, such as the Hamilton Rating Scale for Depression, the Hamilton Rating Scale for Anxiety, and Young's Mania Rating Scale, may be advisable before conclusions are made about whether a psychiatric patient is able to complete an advance directive.

Although the authors of the articles in the May issue mention the concept of "fluctuating capacity," many individuals who are in a seemingly stable and competent phase may not really be so because of the above-mentioned factors. As our knowledge about medical and psychiatric advance directives among patients with severe mental illness gradually improves, we as clinicians need to be aware of the possible confounding factors.

Finally, children with severe mental retardation or autism will never be able to give advance directives.

In the future even if use of both psychiatric and medical advance directives becomes routine clinical practice, the role of surrogate decision makers for persons with mental illness should not be undermined.