While advance directives are quite common for patients with physical impairments, advance directives for people with mental impairments are controversial. In many countries, including Germany, there are as yet no legal provisions for so-called self-binding directives.

After exploring the advantages and drawbacks of self-binding directives under the umbrella of the SALUS project, researchers from Ruhr University Bochum (Germany), King's College London, Charité Berlin and Vrije Universiteit Amsterdam have concluded that the benefits clearly outweigh the risks.

Following a comprehensive literature analysis of pro and con arguments, the team interviewed mental health service users, relatives and mental health professionals about the benefits and risks and drew up recommendations for the implementation of self-binding directives. The results have been published in three papers in The Lancet Psychiatry, European Psychiatry and World Psychiatry. The most recent publication was released on 12 September 2023 in The Lancet.

Defining your preferences for future psychiatric treatment

The hurdles for compulsory psychiatric admission or treatment are high; there must be a risk of significant harm to health. "Yet social and financial damage often occurs already at an earlier stage, which service users regret afterwards," explains Matthé Scholten of the Bochum Institute for Ethics and History of Medicine. People diagnosed with bipolar disorder often engage in risk-taking behavior during manic episodes, during which they might for example spend a lot of money.

Self-binding directives enable service users to specify—while they are capable of giving consent—that they wish to be admitted involuntarily in a psychiatric ward under certain circumstances: for example, if their partner or a friend notices them to be behaving in a certain way that they have previously defined. In the directive, service users can also state which treatments they wish to receive and which they refuse to receive.

Benefits and risks of self-binding directives

"Self-binding directives offer three crucial benefits," as Matthé Scholten sums up. "It ensures greater autonomy for the service user, can prevent financial and social harm, and can also improve the therapeutic relationship and the relationship with relatives. Overall, self-binding directives give service users control over their lives and treatment."

A commonly cited risk, on the other hand, is the risk of undue influence by relatives or physicians in drawing up the directive. While a psychiatrist might believe drug treatment is the best therapy option, the service user might reject it because of severe side effects. "At the end of the day, the content of the self-binding directive must solely reflect the will of the service user. We therefore recommend that it should be drawn up in the presence of a neutral party," says Scholten, outlining a possible solution.

There are also hurdles in terms of implementation; for example, in the event of a psychiatric crisis, it may not be possible to find or access the directive and the treatment may not be carried out in accordance with the wishes of the person concerned. The researchers therefore recommend using a digital infrastructure that complies with data protection requirements.

Three countries in comparison

In one of their studies, the team interviewed stakeholders in Germany, the Netherlands and England about self-binding directives. Among these three countries, self-binding directives are only used in the Netherlands. In Germany, it would be necessary to create the legal framework first.

The results surprised the researchers: "Although the health care systems of the three countries are very different, there was a great deal of overlap in the results," says Scholten. "The advantages outweighed the disadvantages, according to our respondents."

Sufficient resources critical

Having sufficient resources is critical in order to implement self-binding directives. It's vital to draft the relevant directives very carefully. "Moreover, after the treatment is completed, the service user, family member and physician should get together and evaluate whether the treatment was carried out according to the service user's wishes," explains Matthé Scholten. "If not, future treatment should be delivered in a different way or, if the service user requests any changes, these changes should be incorporated in the directive."

The researchers assume that the time invested into this process will pay off. "If you admit service users at the beginning of a crisis, it's likely that they will be hospitalized in the psychiatric ward for a shorter period of time than if you wait until there's a major crisis," concludes the Bochum researcher.