Psychiatric advance directives (PADs) allow individuals with psychiatric conditions to document their preferences for treatment and interactions during a mental health crisis before that crisis occurs. This environmental scan combines evidence from systematic reviews, primary empirical literature, and grey literature to better understand the state of the evidence regarding implementing PADs in community, inpatient, and outpatient contexts.

Psychiatric Advance Directives

A Review of the Evidence

Alejandro Roa Contreras, Skye A. Miner, Melissa Louise Harris-Gersten, Daniel Siconolfi, Nicole K. Eberhart

ResearchPublished Jun 24, 2025

Psychiatric advance directives (PADs) offer individuals with psychiatric conditions the opportunity to document their preferences for treatment and interactions during a mental health crisis before that crisis occurs. In completing a PAD, individuals are encouraged to identify and document their preferences for medication management, setting of care, points of contact, a decisionmaking surrogate, and ways of interacting with emergency response and health care teams. Although PADs have grown in popularity and their legality has been increasingly recognized in international contexts and among individual U.S. states, evidence regarding their use is not well synthesized or documented. In this environmental scan, the authors take a broad approach that combines evidence from systematic reviews, primary empirical literature, and grey literature to better understand the state of the evidence regarding implementing PADs in community, inpatient, and outpatient contexts.

The authors sought to identify the potential and realized benefits of PADs, the barriers to the adoption and implementation of PADs, and promising practices for PAD implementation. This report summarizes those findings and can help inform future efforts to develop and implement PADs. Overall, PADs are a promising tool to improve care for individuals with serious mental illness; however, implementation requires clear legal guidance and clinician buy-in to ensure the effectiveness of PADs.

Key Findings

  • Many U.S. states and other countries legally recognize PADs.
  • Evidence shows that PADs improve autonomy in decisionmaking, reduce coercion in crisis interventions, and lower involuntary hospitalization rates.
  • Barriers to the integration of PADs in crisis planning and management include inconsistent legal recognition across states and jurisdictions, lack of provider understanding and training, and lack of awareness among persons with psychiatric conditions.
  • Promising practices for PAD implementation include clinician training and awareness programs, facilitating PADs with peer worker or clinician support, and implementing clear legal mandates and frameworks.
  • Future studies should focus on defining and measuring consistent outcomes for clinicians, individuals who have completed a PAD, and community members to increase the evidence regarding the use of PADs.
  • Future implementation efforts should focus on ensuring that health care teams are aware of and trained to understand the legal status of PADs and how to use them within their current care environment.

Recommendations

  • Implementation efforts should focus on ensuring that health care teams are trained to understand the legal status of PADs and how to use them within a team's current health care system.
  • Research should focus on measuring the outcomes of PADs (e.g., reduced hospitalizations, patient empowerment, improvement of self-efficacy, cost-effectiveness).
  • PAD researchers should use validated questionnaires and tools to measure outcomes to facilitate comparison and replicability.
  • Studies should better assess socioeconomic characteristics and mental health conditions, including access to health insurance and specific serious mental illnesses, among those who complete a PAD.
  • To ensure that PADs are effective in the real world, policymakers can focus on clear legislation that promotes consistent and uniform knowledge among clinicians, first responders, and hospital systems about when and how PADs can be used.
  • PADs should be integrated with health care and first responder systems so that PADs can be accessed in a time of crisis.

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Roa Contreras, Alejandro, Skye A. Miner, Melissa Louise Harris-Gersten, Daniel Siconolfi, and Nicole K. Eberhart, Psychiatric Advance Directives: A Review of the Evidence. Santa Monica, CA: RAND Corporation, 2025. https://www.rand.org/pubs/research_reports/RRA3464-2.html.
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This research was funded by California counties under the Mental Health Services Act and carried out within the Access and Delivery Program in RAND Health Care.

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