Peer-driven directives lowered hospital admissions in French adults with mental illness

Peer worker–facilitated psychiatric advance directives proved effective in decreasing compulsory hospital admissions and increasing certain positive outcomes for those with mental illness, according to a study published in JAMA Psychiatry.

“In the last 20 years, several randomized clinical trials have assessed the effectiveness of interventions in reducing compulsory psychiatric admissions,” Aurelie Tinland, MD, PhD, of the CEReSS-Health Service Research and Quality of Life Center at Aix-Marseille University School of Medicine in France, and colleagues wrote. “And systematic reviews showed that the most effective were psychiatric advance statements.”

Researchers sought to determine the efficacy of psychiatric advance directives facilitated by peer workers (PW-PAD) for those with three specific mental disorders.

This multicenter, randomized clinical trial was conducted between January 2019 and June 2020, with a 12-month follow-up, across seven French mental health facilities. The study included 394 participants (median age 39, 45% with schizophrenia, 36% with bipolar I disorder, 19% with schizoaffective disorder), randomized to either a group where peer workers were trained to assist in completion of a PAD form (n=196) or a control group (n=198). The primary outcome was the rate of compulsory admission at the 12-month follow-up interval. Overall psychiatric admission rate, therapeutic alliance, quality of life, mental health symptoms, empowerment and recovery outcomes were also investigated.

Results showed that 27% of those in the PW-PAD group had compulsory admissions compared with 39.9% in the control group (risk difference, 0.13; 95% CI, 0.22 to 0.04). Participants in the PW-PAD group also exhibited fewer symptoms (effect size, 0.20; 95% CI, 0.40 to 0.00), greater empowerment (effect size, 0.30; 95% CI, 0.10 to 0.50) and a higher recovery score (effect size, 0.44; 95% CI, 0.24 to 0.65) compared with controls. Additionally, no significant differences were found in the rate of overall admissions, therapeutic alliance score and quality of life.

“Legal and organizational initiatives that promote supported decision-making can develop the activity of peer workers to fulfill this mission,” Tinland and colleagues wrote.