Psychiatric Advance Directives: Closing the Gap Between Evidence and Crisis Care Practice

Psychiatric advance directives (PADs) are designed to preserve patient preferences during psychiatric crises and reduce reliance on coercive interventions. Although PADs are supported by randomized and observational evidence, they remain infrequently used in US behavioral health systems. This Policy Perspective argues that PAD underuse reflects failures in system design rather than lack of effectiveness or patient interest. We describe the magnitude and consequences of PAD under-implementation, including its implications for crisis-based care, racial and ethnic inequities, and system inefficiency. We then examine how existing policies and health system structures limit PAD accessibility and use during psychiatric emergencies, despite evidence that facilitated PADs can improve outcomes. Finally, we outline policy and system-level reforms to support PAD implementation, including investment in infrastructure, reimbursement for facilitation, integration into crisis response workflows, and equity-focused community partnerships. Advancing PAD implementation represents a practical opportunity to reduce coercive crisis responses and strengthen equity in behavioral health care.