Understanding the Personal and Clinical Utility of Psychiatric Advance Directives: A Qualitative Perspective

Psychiatric advance directives (PADs) are legal tools that allow competent individuals to declare preferences for future mental health treatment when they may not be capable of doing so as a result of a psychiatric crisis. PADs allow individuals to maintain self–determination during times when they are most vulnerable to loss of autonomy and in need of assistance to make their preferences known and honored. This article describes the content of twenty–eight open–ended, semi–structured qualitative interviews of adults with PADs who have experienced psychiatric crises. The qualitative analysis revealed three major themes from the interviews: (1) PADs as tools for empowerment and self–determination, (2) limited knowledge of PADs among service providers; and (3) difficulties communicating PADs to inpatient staff. In general, many participants expressed enthusiasm of the implementation of PADs but concern regarding clinicians’ general lack of awareness about them. Additionally, some consumers discussed discomfort in even mentioning that they had a PADto clinicians for fear of a negative response from them, or some type of involuntary treatment during their hospitalization. However, participants consistently viewed PADs as a positive tool to promote autonomy with the potential to facilitate stronger patient–provider relationships. Therefore, when working with individuals in psychiatric crisis who have a PAD, and who have never before experienced a sense of control over their own treatment, clinicians must recognize the potential troubling disequilibrium this sense of control may engender. In sum, though the most significant challenges facing the implementation of PADs involve clinicians’ familiarity with and education about PADs, much promise for the future growth of PADs lies in the benefits perceived by the patients

Psychiatric Advance Directives and Social Workers: An Integrative Review

Psychiatric Advance Directives (PADs) are legal documents that allow individuals to express their wishes for future psychiatric care and to authorize a legally appointed proxy to make decisions on their behalf during incapacitating crises. PADs are viewed as an alternative to the coercive interventions that sometimes accompany mental health crises for persons with mental illness. Insofar as coercive interventions can abridge clients’ autonomy and self-determination -- values supported by the Profession’s Code of Ethics -- social workers have a vested interest in finding ways to reduce coercion and increase autonomy and self-determination in their practice. However, PADs are also viewed as having the potential to positively affect a variety of other clinical outcomes, including but not limited to treatment engagement, treatment satisfaction, and working alliance. This article reviews the clinical and legal history of PADs and empirical evidence for their implementation and effectiveness. Despite what should be an inherent interest in PADs, and the fact that laws authorizing PADs have proliferated in the past decade, there is little theoretical or empirical research in the social work literature

Intensive Case Management Before and After Prison Release is No More Effective Than Comprehensive Pre-Release Discharge Planning in Linking HIV-Infected Prisoners to Care: A Randomized Trial

Imprisonment provides opportunities for the diagnosis and successful treatment of HIV, however, the benefits of antiretroviral therapy are frequently lost following release due to suboptimal access and utilization of health care and services. In response, some have advocated for development of intensive case-management interventions spanning incarceration and release to support treatment adherence and community re-entry for HIV-infected releasees. We conducted a randomized controlled trial of a motivational Strengths Model bridging case management intervention (BCM) beginning approximately 3 months prior to and continuing 6 months after release versus a standard of care prison-administered discharge planning program (SOC) for HIV-infected state prison inmates. The primary outcome variable was self-reported access to post-release medical care. Of the 104 inmates enrolled, 89 had at least 1 post-release study visit. Of these, 65.1% of BCM and 54.4% of SOC assigned participants attended a routine medical appointment within 4 weeks of release (P >0.3). By week 12 post-release, 88.4% of the BCM arm and 78.3% of the SOC arm had at attended at least one medical appointment (P = 0.2), increasing in both arms at week 24–90.7% with BCM and 89.1% with SOC (P >0.5). No participant without a routine medical visit by week 24 attended an appointment from weeks 24 to 48. The mean number of clinic visits during the 48 weeks post release was 5.23 (SD = 3.14) for BCM and 4.07 (SD = 3.20) for SOC (P >0.5). There were no significant differences between arms in social service utilization and re-incarceration rates were also similar. We found that a case management intervention bridging incarceration and release was no more effective than a less intensive pre-release discharge planning program in supporting health and social service utilization for HIV-infected individuals released from prison

What Do Farmers Need for Suicide Prevention: Considerations for a Hard-to-Reach Population

Anna Scheyett,1,2 Ian Lee Marburger,2 Andrea Scarrow,1 Stephanie M Hollifield,1 Jennifer Ward Dunn1 1College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, USA; 2School of Social Work, University of Georgia, Athens, GA, USACorrespondence: Anna Scheyett, School of Social Work, University of Georgia, 279 Williams St, Athens, GA, USA, Email [email protected]: Farmers have suicide rates much higher than the general population, with elevated mental health symptoms and high stress levels. Farmers are a hard-to-reach population due to occupational demands and a culture where conversations about mental health are often stigmatizing. This study explored ways to tailor suicide prevention strategies to unique characteristics of farmers by speaking with groups close to farmers who were open to discussing stress and suicide prevention: women married to farmers and agricultural Extension agents.Methods: Focus groups with women married to farmers (N=29) and interviews with agricultural agents from the university’s local Cooperative Extension offices (N=13) from rural Georgia counties explored effective ways outreach and education about suicide prevention, mental health, and coping could be provided to farmers. Using a thematic analysis approach, qualitative coding was completed by two researchers (Cohens kappa=0.86), with initial codes collapsed into common themes.Results: Four themes were identified: 1) Barriers due to the nature of farming, including time demands of farming and cultural stigma in help-seeking; 2) Acceptable messaging, including framing conversations as part of general health; 3) Make information accessible by making it brief, clear, and omnipresent through multiple media; and 4) Elements of effective information and education, including emphasizing “you’re not alone” and connection, how to access supports and crisis services, educating people close to farmers, and motivating farmers by emphasizing that they could help another farmer with the information.Conclusion: Due to farmers’ stoic identities and reluctance to admit mental health struggles, speaking with those close to farmers may help us better understand what is needed to tailor farmer suicide prevention strategies. The insights shared by participants suggest that culturally responsive outreach and education strategies, strengthening relationships through peer support, and gatekeeper training with specific trusted others are important ways to tailor suicide prevention strategies for this hard-to-reach group.Keywords: agricultural stress, agricultural suicide, rural suicide prevention, farmer culture, mental health stigma, rural mental healt