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Advance Decision Making in Bipolar: A Systematic Review

Research output: Contribution to journalArticle

Lucy Stephenson, Lucy Stephenson, Gareth Owen, Alexander Ruck Keene, Rifkin Larry, Tania Gergel, Astrid Gieselmann, Matthe Scholten

Original languageEnglish
JournalFrontiers in Psychiatry
Published4 Sep 2020

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Abstract

Introduction: “Advance decision making” (ADM) refers to people planning for a future Q10
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
outcomes from ADM activities. This research should focus on clarifying: causal assumptions around ADM, the outcomes which are valued by key stakeholders, barriers
to achieving these outcomes, stakeholder opinions on supporting ‘self-binding’ and the
development and evaluation of models of ADM which are tailored for fluctuating DMC-T.

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