A psychiatric advance directive — usually called a PAD — is a legal document that lets you record your treatment preferences for psychiatric care while you are well, so that if a future crisis takes away your capacity to decide, your voice is still part of the room. It is one of the most powerful tools available for people with schizophrenia, schizoaffective disorder, bipolar disorder, or any condition where capacity can fluctuate. And it is one of the most underused.
A PAD is a legally recognised document where you specify, in advance, which medications, treatments, hospitals, and contacts you prefer (and which you do not) in case you experience a psychiatric crisis that compromises your decision-making.
Where PADs come from
Psychiatric advance directives grew out of the patient rights movement of the 1980s and 90s, building on the older concept of medical advance directives (living wills). They are now recognised in some form in most US states. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) has been a strong advocate for their wider use.
Two parts to a typical PAD
Most state PAD statutes contemplate two pieces:
Instructions
Your written preferences about treatment. These can include:
- Medications you want to take if needed
- Medications you want to avoid (and why — past bad reactions, side effects, interactions)
- Preferred and refused hospitals or units
- Preferences about restraints and seclusion
- Whether you consent to or refuse ECT
- People to be notified during a crisis
- People not to be notified
- Preferred coping strategies and de-escalation approaches
- Care for your home, pets, dependents, and obligations during hospitalisation
- Communication preferences with family and employers
Healthcare proxy / agent
An optional but often included component: naming someone to make decisions for you if you become incapacitated. This overlaps with a healthcare power of attorney. Some states use one document; some use two.
What PADs can and cannot do
A PAD is a directive, not a guarantee. State law determines the binding force, and there are limits:
- Most states require treating clinicians to follow the PAD or document specific reasons for departing from it
- PADs generally cannot demand treatment that is medically inappropriate
- PADs cannot override a valid court order for involuntary commitment in many states
- Refusal of certain treatments (like emergency medication during a true crisis) may be legally overridable in some jurisdictions
Even where not legally binding in every detail, a PAD has powerful practical force. Clinicians take written preferences seriously when they are well-articulated, and a PAD provides the only documented voice of a person who may not be able to speak for themselves at the moment.
How to create a PAD
- Look up your state's specific PAD law and form. The National Resource Center on Psychiatric Advance Directives has state-by-state information.
- Think about what worked and what didn't in past episodes — talk to family, friends, your treatment team
- Draft the document. State forms are usually fine; some people add a personal narrative attachment.
- Sign with the required formalities (witnesses and/or notary, depending on state)
- Distribute copies — to your agent, your psychiatrist, your therapist, your primary care physician, the hospital you would go to, your closest family members, and yourself (in your wallet or phone, with a note that the full document is at home)
- Review every year or after any significant change in treatment or circumstances
Writing a useful PAD
The best PADs are specific, practical, and grounded in real experience. Useful entries:
- "Risperidone caused severe akathisia in 2024. I do not want it again."
- "Olanzapine has worked best for me. Please consider it first if I cannot speak."
- "My cat needs to be picked up by my sister Anna (number XXX) within 12 hours of any hospitalisation."
- "Please call my employer's HR (number XXX) only after I or my agent has approved a script."
- "During acute episodes I respond better to quiet single rooms and minimal stimulation."
- "I do not want my father informed of my hospitalisation."
Vague PADs ("I want good care") are less useful than specific ones.
Choosing your agent
If you name a healthcare agent, choose someone who knows you, can be reached during a crisis, will follow your wishes (not just their own preferences), and can communicate effectively with clinicians. Always name a backup. Discuss the document with both before signing.
How clinicians use PADs
When you arrive at a hospital, especially through emergency services, ask staff to access your PAD. Many states have central registries; in others, the document needs to be brought in. Some hospitals are now incorporating PAD review into routine intake. SAMHSA's PAD resources are training a growing number of providers in PAD-respectful care.
A PAD is a legal document. A crisis plan (or WRAP) is a personal planning tool. Both are useful — see our pieces on crisis coping plans and WRAP.
Revising and revoking
You can revise or revoke a PAD at any time while you have capacity. Best practice: distribute new copies to everyone who has the old document, and explicitly note the revocation if there are changes. In some states, you cannot revoke a PAD while incapacitated — a feature, not a bug, designed to prevent crisis-state revocations from undoing carefully made earlier decisions.
Resources for making a PAD
- National Resource Center on Psychiatric Advance Directives — state-by-state forms, training videos
- SAMHSA — federal resources on PAD implementation
- NAMI — local affiliates can help with practical use
- Your state's Protection and Advocacy agency
- State mental health agencies — many have PAD information
If you are considering one
The hardest part of writing a PAD is sitting with the reality that you may have another crisis. That sitting is itself useful — it lets you plan in a way that future-you will benefit from. People who have made PADs frequently describe a sense of agency that the document itself provides, even before any crisis comes.
For deeper context, see our pieces on mental health POAs, guardianship and alternatives, and your rights in a psychiatric hospital.
This article is for educational purposes only and is not legal, medical, or financial advice. Benefits programs change frequently and rules vary by state. Always verify current requirements with the Social Security Administration, your state Medicaid office, a benefits counsellor, or a qualified attorney before making decisions. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.