title: Unpacking the psychiatric advance directive in low-resource settings: an exploratory qualitative study in Tamil Nadu, India.
abstract: BACKGROUND
  Psychiatric advance directives, a tool to document preferences for care in advance of decisional incapacity, have been shown to benefit persons with mental illness in a number of countries through improving medication adherence, reducing symptoms from escalating in a crisis, accelerating recovery, and enhancing service user autonomy. While concepts such as autonomy are important in a number of high-income country settings, it remains unclear whether tools like psychiatric advance directives are suitable in a different context. The recent introduction of the psychiatric advance directive into draft legislation in India prompts the question as to how feasible psychiatric advance directives are in the Indian context. The aim of this study is to explore the feasibility and utility of PADs in India, with a focus on the need for individual control over decision making and barriers to implementation, by exploring views of its central stakeholders, service users and carers.
  
  
  METHODS
  Qualitative semi-structured interviews (n = 51) with clients (n = 39) and carers (n = 12) seeking mental health treatment at outpatient clinics in urban and rural settings provided by a non-profit organisation in Tamil Nadu, India.
  
  
  RESULTS
  Clients engaged in a number of forms of decision-making (passive, active, and collaborative) depending on the situation and decision at hand, and had high levels of self-efficacy. Most clients and carers were unfamiliar with PADs, and while some clients felt it is important to have a say in treatment wishes, carers expressed concerns about service user capacity to make decisions. After completing PADs, clients reported an increase in self-efficacy and an increased desire to make decisions.
  
  
  CONCLUSIONS
  The introduction of psychiatric advance directives in India appears to be associated with positive outcomes for some service users, however, there is a need to better understand how this tool can be adapted to better suit the care context in India and hold meaning and value for service users to complete.
authors.affiliation: Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands. l.s.shields@vu.nl.
authors.forename: Laura S
authors.initials: LS
authors.lastname: Shields
authors.forename: Soumitra
authors.initials: S
authors.lastname: Pathare
authors.forename: Selina Dm
authors.initials: SD
authors.lastname: van Zelst
authors.forename: Sophie
authors.initials: S
authors.lastname: Dijkkamp
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Narasimhan
authors.forename: Joske Gf
authors.initials: JG
authors.lastname: Bunders