title: Facilitation of Psychiatric Advance Directives by Peers and Clinicians on Assertive Community Treatment Teams.
abstract: OBJECTIVE
  Psychiatric advance directives (PADs) provide a legal mechanism for competent adults to document care preferences and authorize a surrogate to make treatment decisions. In a controlled research setting, an evidence-based intervention, the facilitated psychiatric advance directive (FPAD), was previously shown to overcome most barriers to PAD completion. This study examined implementation of the FPAD intervention in usual care settings as delivered by peer support specialists and nonpeer clinicians on assertive community treatment (ACT) teams.
  
  
  METHODS
  A total of 145 ACT consumers were randomly assigned, within teams, to FPAD with facilitation by either a peer (N=71) or a clinician (N=74). Completion rates and PAD quality were compared with the previous study's standard and across facilitator type. Logistic regression was used to estimate effects on the likelihood of PAD completion.
  
  
  RESULTS
  The completion rate of 50% in the intent-to-treat sample (N=145) was somewhat inferior to the prior standard (61%), but the rate of 58% for the retained sample (those who completed a follow-up interview, N=116) was not significantly different from the standard. Rates for peers and clinicians did not differ significantly from each other for either sample. PAD quality was similar to that achieved in the prior study. Four consumer variables predicted completion: independent living status, problematic substance use, length of time served by the ACT team, and no perceived unmet need for hospitalization in crisis.
  
  
  CONCLUSIONS
  Peers and clinicians can play a crucial role in increasing the number of consumers with PADs, an important step toward improving implementation of PADs in mental health care.
authors.affiliation: Dr. Easter, Dr. Swanson, Dr. Robertson, and Dr. Swartz are with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina. Dr. Moser is with the Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
authors.forename: Michele M
authors.initials: MM
authors.lastname: Easter
authors.affiliation: Dr. Easter, Dr. Swanson, Dr. Robertson, and Dr. Swartz are with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina. Dr. Moser is with the Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Swanson
authors.affiliation: Dr. Easter, Dr. Swanson, Dr. Robertson, and Dr. Swartz are with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina. Dr. Moser is with the Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
authors.forename: Allison G
authors.initials: AG
authors.lastname: Robertson
authors.affiliation: Dr. Easter, Dr. Swanson, Dr. Robertson, and Dr. Swartz are with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina. Dr. Moser is with the Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
authors.forename: Lorna L
authors.initials: LL
authors.lastname: Moser
authors.affiliation: Dr. Easter, Dr. Swanson, Dr. Robertson, and Dr. Swartz are with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina. Dr. Moser is with the Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
authors.forename: Marvin S
authors.initials: MS
authors.lastname: Swartz
mesh_terms: D000293:Adolescent; D000328:Adult; D016223:Advance Directives / Q000706:statistics & numerical data; D000368:Aged; D003156:Community Mental Health Services / Q000706:statistics & numerical data; D055317:Evidence-Based Practice / Q000706:statistics & numerical data; D005260:Female; D006282:Health Personnel / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000628:therapy; D008875:Middle Aged; D010379:Peer Group; D055815:Young Adult
keywords: Advance directives/proxies; Assertive community treatment; Community mental health services; Recovery; Staff relationships/roles