Psychosis and COVID-19: is it time to pre-emptively revise advanced directives?
Authors: Satish Suhas, Naren P Rao
Journal: The Lancet Psychiatry (2021)

Historically, people with psychosis have been stripped of their right to autonomous decisions regarding their treatment.1Pons EV Salvador-Carulla L Calcedo-Barba A et al.The capacity of schizophrenia and bipolar disorder individuals to make autonomous decisions about pharmacological treatments for their illness in real life: a scoping review.Health Sci Rep. 2020; 3: e179Crossref PubMed Scopus (10) Google Scholar Lack of insight and impaired decision-making capacity is often cited as the justification for this authoritarian view. However, it is increasingly recognised that decision-making capacity in people with psychosis is dynamic, with intermittent periods of intactness.2Kim SYH Appelbaum PS Swan J et al.Determining when impairment constitutes incapacity for informed consent in schizophrenia research.Br J Psychiatry. 2007; 191: 38-43Crossref PubMed Scopus (50) Google Scholar Worldwide, there has been growing advocacy to grant more autonomy for people with psychosis to make decisions regarding their treatment and life.3Gostin LO Gable L The human rights of persons with mental disabilities: a global perspective on the application of human rights principles to mental health.Md L Rev. 2004; 63: 20PubMed Google Scholar An advanced directive is one such legal provision wherein people with mental illness can decide on the nature of health care they wish to receive. If the COVID-19 pandemic has affected the very fabric of everyday life, then can an advanced directive made before the pandemic genuinely serve its intended purpose? In this instance, a pre-commitment directive might not be the true reflection of autonomy across the continuum of time given the dynamic nature of changes. This does not mean, however, that the autonomy of the patient should be compromised. It is during these challenging times that advanced directives are to be protected with utmost sanctity. This brings us to the next challenge about how a mental health-care provider should manage this conundrum. Revised advanced directives might be necessary to indicate preferred treatment choices, given the re-assessment of the risks and benefits of health-care delivery during the pandemic. Decisions regarding hospitalisation, initiating clozapine, receiving long-acting injectables, and electroconvulsive therapy might pose different risk–benefit profiles after the pandemic onset. Additionally, given the increased mortality rates in people with psychosis secondary to COVID-19,4Nemani K Li C Olfson M et al.Association of psychiatric disorders with mortality among patients with COVID-19.JAMA Psychiatry. 2021; (published online Jan 27.)https://doi.org/10.1001/jamapsychiatry.2020.4442Crossref PubMed Scopus (270) Google Scholar dynamic revisions in advanced directives should also reflect the decisions regarding COVID-19 treatment—eg, whether to receive the vaccine or not, type of vaccine, and the mode of delivery. Pandemics might come and go but medical ethics principles should stand resolute against mitigated or unmitigated disasters. Dynamic, advanced directives in line with the rapidly evolving pandemic situation will add more value to patients' autonomy. There should be pre-emptive advocacy from mental health professionals to educate people with psychosis about the evolving conundrums and motivate them to draft revised advanced directives. This education would genuinely better represent the will and the voice of people with psychosis. Although challenging to implement, this crucial aspect of mental health-care delivery needs more attention to ensure that the best interests of people with psychosis are given due consideration. We declare no competing interests