Advance Decision Making in Bipolar: A Systematic Review

Abstract

Introduction: "Advance decision making" (ADM) refers to people planning for a future when they may lose the capacity to make decisions about treatment (decision making capacity for treatment or DMC-T). This can occur in a variety of physical and mental health scenarios. Statutory provision for ADM is likely to be introduced to mental health legislation in England and Wales, which will support planning for mental health crises. Conceptually, it may have particular utility for people with Bipolar Affective Disorder (bipolar) due to the pattern of rapid loss and then recovery of DMC-T during episodes of illness. Furthermore, ADM is recommended by clinical experts in bipolar. However, the empirical evidence base for ADM in bipolar is unclear. Therefore, a systematic review is required to collate available evidence and define future research directions. Methods: A PRISMA concordant systematic review of empirical literature on the use of ADM in bipolar. Results: We found 13 eligible articles which reported on 11 studies. Of the eligible studies 2 used a mixed methods design, 8 were quantitative descriptive studies and 1 was a randomised controlled trial. Outcomes of included studies fell into 4 categories: Interest in ADM, type of ADM preferred, barriers to completing ADM and impact of ADM. The available evidence suggests that people with bipolar are interested in engaging with ADM which is supported, collaborative and allows them to state treatment requests and refusals. Conclusions: Evidence in this area is limited. Clinicians should be aware that service users with bipolar are likely to value their support in creating ADM documents. In addition, it seems that people with bipolar may face fewer barriers and achieve greater success with ADM compared to those with other severe mental illnesses. Given the greater focus and likely demand for ADM following upcoming legal reform, further research is urgently needed to ensure available resources are most effectively targeted to achieve the best

Reasons for endorsing or rejecting self-binding directives in bipolar disorder: a qualitative study of survey responses from UK service users

“…This empirical evidence supports the view that mental health law and practice should be adapted to accommodate a feasible self-binding directive model 1 , 2 , 3 and, more generally, that we cannot define the successful outcomes of advance decision making in mental health purely in terms of avoidance of involuntary and inpatient treatment. 12 , 16 Yet, despite overall predominance of endorsement of the use of self-binding directives, the presence of clear rejections and ambivalence was based on varied concerns, such as logistics, or endangering autonomy, capacity, and clinical judgment, emphasising the need to take individual values and opinions into account. Such rejections and ambivalence certainly show that endorsement of the use of self-binding directives is not unanimous among people with bipolar disorder and that there are concerns that need to be addressed.…”

“…We focused on people with bipolar disorder because severe periods of bipolar illness are typically episodic and repetitive and often feature a loss of decision-making capacity for treatment that is regained during recovery, and because there is a paucity of research on advance decision making for this condition. 11 , 12 …”

Preparing for Mental Health Act reform: Pilot study of co-produced implementation strategies for Advance Choice Documents

“…To address our first aim service user participants along with a supporting family member/friend and a treating health care professional were invited to take part in creating a prototype ACD using a collaborative template called a ‘Crisis PACk’ (available in a data repository). This template was based on a document co-produced with stakeholders during a previous study ( Stephenson et al , 2020b ) and adapted to the needs of the local setting. Of note, the template also offers service users the option to ‘self-bind’ i.e.…”

“…to request compulsory treatment in advance even if they anticipate that when they are unwell and the treatment is needed they are likely to refuse it. This option was included in response to evidence that it may have particular salience for people with bipolar ( Gergel et al, 2021 ; Gergel & Owen, 2015 ; Stephenson et al, 2020a )…”

Case Vignettes in Transplant Psychiatry Ethics

“…In rare instances, individuals with known bipolar disorder, or other conditions that may afflict a patient temporarily with poor judgment, might compose an advanced directive, to be enacted to override a potentially bad medical decision during psychiatric exacerbation. 14 Our patient, having never previously suffered from major psychiatric illness save for intermittent anxiety, would not have known to prepare such a document. Likewise, the mania which curtailed his judgment might theoretically be considered to be of iatrogenic origin, as antidepressants in susceptible individuals are known to push, or "flip," patients into mania, and hence potentially in the realm of malfeasance; it is a known risk to treatment, however, and antidepressant exposure may not elevate the risk of mania significantly as once presumed.…”