Completing psychiatric advance directives (PADs) facilitated by peer workers (PW) was effective at decreasing compulsory hospital admissions and increasing mental health outcomes, including recovery, among patients with mental disorders. These findings, from a multicenter randomized clinical trial, were published in JAMA Psychiatry.

The Peer Worker-Facilitated Psychiatric Advance Directive Study (DAiP) study was conducted at 7 mental health facilities in France between 2019 and 2021. Patients (N=394) who had been involuntarily hospitalized within the past 12 months for schizophrenia, bipolar I disorder (BP), or schizoaffective disorder were randomized in a 1:1 ratio to receive PW-PAD (n=196) or standard care (n=198).

The PW-PAD intervention consisted of assisting patients with completing PAD documentation about future treatment and support strategies, describing early signs of relapse, and discussing coping strategies. The primary outcome was the rate of compulsive hospitalization in the following 12 months and secondary outcomes were care-related and patient-reported mental health outcomes.

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The intervention and control cohorts comprised 64.8% and 56.6% men, aged mean 37.4 (SD, 11.7) and 41.0 (SD, 12.7) years, 44.1% and 46.5% had schizophrenia, 33.8% and 36.9% had BP, 22.1% and 16.7% had schizoaffective disorder, 61.2% and 69.2% had one or more somatic comorbidities, and the average number of admissions in the previous year was 1.5 (SD, 0.9) and 1.4 (SD, 0.8), respectively.

PAD was completed by 54.6% of the intervention and 7.1% of the control cohorts. PAD was used during a subsequent crisis among 14.8% and 2.5% of intervention and control cohorts, respectively.

Compulsory hospital admissions were reduced among the PW-PAD cohort (adjusted odds ratio [aOR], 0.58; 95% CI, 0.37-0.92; P =.007). The intervention was also related with significant changes to the modified Colorado Symptom Index (d, -0.20; 95% CI, -0.40 to 0.00; P =.03), the Empowerment Scale (d, 0.30; 95% CI, 0.10-0.50; P =.003), and the Recovery Assessment Scale (d, 0.44; 95% CI, 0.24-0.65; P <.001).

Results from sensitivity analyses which imputed missing data were similar to the main analysis.

This study was limited by the fact that the follow-up was interrupted by the COVID-19 pandemic.

The study authors concluded, “Among people living with schizophrenia, bipolar I disorder, or schizoaffective disorder, the use of PW-PADs was associated with a significant decrease in compulsory admissions and a significant increase in some mental health outcomes (self-perceived symptoms, empowerment, and recovery). These findings support the use of PW-PADs for people with schizophrenia, bipolar I disorder, or schizoaffective disorder.”


Tinland A, Loubière S, Mougeot F, et al. Effect of psychiatric advance directives facilitated by peer workers on compulsory admission among people with mental illness: A randomized clinical trial. JAMA Psychiatry. 2022;e221627. doi:10.1001/jamapsychiatry.2022.1627