***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Background : Psychiatric advance directives are intended to enable self-determined treatment for patients who lose decisional capacity , and thus reduce the need for coercive interventions such as police transport , involuntary commitment , seclusion and restraints , and involuntary medications during mental health crises ; whether PADs can help prevent the use of these interventions in practice is unknown . Aims : This study examined whether completion of a Facilitated Psychiatric Advance Directive ( F-PAD ) was associated with reduced frequency of coercive crisis interventions . Method : The study prospect ively compared a sample of PAD completers ( n = 147 ) to non-completers ( n = 92 ) on the frequency of any coercive interventions , with follow-up assessment s at 6 , 12 , and 24 months . Repeated- measures multiple regression analysis was used to estimate the effect of PADs . Models controlled for relevant covariates including a propensity score for initial selection to PADs , baseline history of coercive interventions , concurrent global functioning and crisis episodes with decisional incapacity . Results : F-PAD completion was associated with lower odds of coercive interventions ( adjusted OR = 0.50 ; 95 % CI = 0.26–0.96 ; p < 0.05 ) . Conclusions : PADs may be an effective tool for reducing coercive interventions around incapacitating mental health crises . Less coercion should lead to greater autonomy and self-determination for people with severe mental illness Background Crises and ( involuntary ) admissions have a strong impact on patients and their caregivers . In some countries , including the Netherl and s , the number of crises and ( involuntary ) admissions have increased in the last years . There is also a lack of effective interventions to prevent their occurrence . Previous research has shown that a form of psychiatric advance statement – joint crisis plan – may prevent involuntary admissions , but another study showed no significant results for another form . The question remains which form of psychiatric advance statement may help to prevent crisis situations . This study examines the effects of two other psychiatric advance statements . The first is created by the patient with help from a  patient 's advocate ( Patient Advocate Crisis Plan : PACP ) and the second with the help of a clinician only ( Clinician facilitated Crisis Plan : CCP ) . We investigate whether patients with a PACP or CCP  show fewer emergency visits and ( involuntary ) admissions as compared to patients without a psychiatric advance statement . Furthermore , this study seeks to identify possible mechanisms responsible for the effects of a PACP or a CCP . Methods / Design This study is a r and omised controlled trial with two intervention groups and one control condition . Both interventions consist of a crisis plan , facilitated through the patient 's advocate or the clinician respectively .  Out patients with psychotic or bipolar disorders , who experienced at least one psychiatric crisis during the previous two years , are r and omly allocated to one of the three groups . Primary outcomes are the number of emergency ( after hour ) visits , ( involuntary ) admissions and the length of stay in hospital . Secondary outcomes include psychosocial functioning and treatment satisfaction . The possible mediator variables of the effects of the crisis plans are investigated by assessing the patient 's involvement in the creation of the crisis plan , working alliance , insight into illness , recovery style , social support , locus of control , service engagement and coping with crises situations . The interviews take place before r and omisation , nine month later and finally eighteen months after r and omisation . Discussion This study examines the effects of two types of crisis plans . In addition , the results offer an underst and ing of the way these advance statements work and whether it is more effective to include a patients ' advocate in the process of creating a psychiatric advance statement . These statements may be an intervention to prevent crises and the use of compulsion in mental health care . The strength and limitations of this study are discussed . Trial registration Current Controlled Trails NTR1166 OBJECTIVE Despite the frequent use of the Positive and Negative Syndrome Scale ( PANSS ) for rating the symptoms of schizophrenia , the clinical meaning of its total score and of the cut-offs that are used to define treatment response ( e.g. at least 20 % or 50 % reduction of the baseline score ) are as yet unclear . We therefore compared the PANSS with simultaneous ratings of Clinical Global Impressions ( CGI ) . METHOD PANSS and CGI ratings at baseline ( n = 4091 ) , and after one , two , four and six weeks of treatment taken from a pooled data base of seven pivotal , multi-center antipsychotic drug trials on olanzapine or amisulpride in patients with exacerbations of schizophrenia were compared using equipercentile linking . RESULTS Being considered " mildly ill " according to the CGI approximately corresponded to a PANSS total score of 58 , " moderately ill " to a PANSS of 75 , " markedly ill " to a PANSS of 95 and severely ill to a PANSS of 116 . To be " minimally improved " according to the CGI score was associated with a mean percentage PANSS reduction of 19 % , 23 % , 26 % and 28 % at weeks 1 , 2 , 4 and 6 , respectively . The corresponding figures for a CGI rating " much improved " were 40 % , 45 % , 51 % and 53 % . CONCLUSIONS The results provide a better framework for underst and ing the clinical meaning of the PANSS total score in drug trials of schizophrenia patients with acute exacerbations . Such studies may ideally use at least a 50 % reduction from baseline cut-off to define response rather than lower thresholds . In treatment resistant population s , however , even a small improvement can be important , so that a 25 % cut-off might be appropriate BACKGROUND An advance directive is a statement of a person 's preferences for treatment , should he or she lose capacity to make treatment decisions in the future . AIMS To evaluate whether use of advance directives by patients with mental illness leads to lower rates of compulsory readmission to hospital . METHOD In a r and omised controlled trial in two psychiatric services in inner London , 156 in- patients about to be discharged from compulsory treatment under the Mental Health Act were recruited . The trial compared usual psychiatric care with usual care plus the completion of an advance directive . The primary outcome was the rate of compulsory readmission . RESULTS Fifteen patients ( 19 % ) in the intervention group and 16 ( 21 % ) in the control group were readmitted compulsorily within 1 year of discharge . There was no difference in the numbers of compulsory readmissions , numbers of patients readmitted voluntarily , days spent in hospital or satisfaction with psychiatric services . CONCLUSIONS Users ' advance instruction directives had little observable impact on the outcome of care at 12 months BACKGROUND Patients and doctors often have divergent views on care needs . AIMS To examine whether providing patients with an opportunity to identify and discuss their needs would improve communication and induce changes in care . METHOD Patients with schizophrenia ( n=134 ) were r and omly allocated to either st and ard care or use of the Two-Way Communication Checklist ( 2-COM ) . Before seeing their clinician for a routine follow-up , participants in the active intervention group were given 2-COM , a list of 20 common needs , and told to indicate those areas they wanted to discuss with their doctor . Outcomes were assessed immediately and again after 6 weeks . RESULTS Using 2-COM induced a stable improvement of patient-reported quality of patient-doctor communication ( B=0.33 , P=0.031 ) , and induced changes in management immediately after the intervention ( OR=3.7 , P=0.009 ; number needed to treat , 6 ) . Treatment change was more likely in patients with more reported needs , and needs most likely to induce treatment change displayed stronger associations with non-medication than with medication changes . CONCLUSIONS A simple intervention to aid people in discussion of their needs results in improved communication and changes in management Summary Advance directive legislation has been in place throughout much of the United States for nearly 3 decades . The right to give an informed consent to or refusal of medical treatment has been recognized by state and federal courts , and that right has been determined to survive the loss of decisional capacity and may be exercised through the execution of instructional or proxy directives . Despite these developments . the percentage of the adult population with a formal advance directive of any type has never exceeded 15 % . Moreover , a remarkable number of these directives are ambiguous and /or their existence is unknown to the physicians who are expected to rely upon them . Even unambiguous directives may not be followed at the critical stage in the trajectory of a patient ’s illness , and the accountability for such disregard by health care institutions or professionals is negligible to nonexistent . Nevertheless , there is real potential for advance directives , as a key element to sound advance care planning , to fulfill their initial promise as instruments of the prospect i ve autonomy of patients . In order for that potential to be realized , primary care physicians must embrace advance care planning as a part of their professional responsibility to patients BACKGROUND Since 1991 , hospitals have asked patients whether they have advance directives , but few patients complete these documents . We assessed two simple interventions to improve completion of advance directives among elderly or chronically ill out patients . METHODS We conducted a cluster r and omized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center . Patients were either > or = 70 years of age or > or = 50 years old with a chronic illness . The study comprised three arms : physician reminders recommending documentation of advance directives , physician reminders plus mailing advance directives to patients together with educational literature , or neither intervention ( control ) . The main outcome measure was completion of an advance directive . RESULTS After 28 weeks , 1.5 % ( 5/332 ) of patients in the physician reminder group , 14 % ( 38/277 ) in the physician reminder plus patient mailing group , and 1.8 % ( 5/286 ) in the control group had completed advance directives . In multivariate analyses , patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives ( odds ratio [ OR ] = 5.9 ; 95 % confidence interval [ CI ] : 1.5 to 22 ) , whereas patients in the physician reminder-only group were no more likely than controls to have completed advance directives ( OR = 0.88 ; 95 % CI : 0.21 to 3.7 ) . CONCLUSION Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents . A physician reminder alone did not have an effect Objective Psychiatric advance directives ( PADs ) allow individuals to plan for future mental health treatment . However , little is known about barriers to PAD completion . This paper examines an intervention ’s effect in reducing barriers to PAD completion . Method Patients were r and omly assigned to a facilitated PAD session or control group .  Barriers associated with ( 1 ) the PAD documents and ( 2 ) external support for PADs were assessed at baseline ( n = 462 ) , 6 months ( n = 380 ) and 1 year ( n = 362 ) . Results There were no significant baseline between-group differences on the two barriers . However , at follow-up both barriers were significantly lower in the experimental group . Further , barriers were predictive of PAD completion . Conclusions Structured facilitation can significantly reduce barriers to PAD completion . However , the intervention did not eliminate barriers . Findings are discussed in the context of possible system-level changes to further reduce barriers to PAD completion The authors estimated components of variance and intraclass correlation coefficients ( ICCs ) to aid in the design of complex surveys and community intervention studies by analyzing data from the Health Survey for Engl and 1994 . This cross-sectional survey of English adults included data on a range of lifestyle risk factors and health outcomes . For the survey , households were sample d in 720 postal code sectors nested within 177 district health authorities and 14 regional health authorities . Study subjects were adults aged 16 years or more .  ICCs and components of variance were estimated from a nested r and om-effects analysis of variance . Results are presented at the district health authority , postal code sector , and household levels . Between-cluster variation was evident at each level of clustering . In these data , ICCs were inversely related to cluster size , but design effects could be substantial when the cluster size was large . Most ICCs were below 0.01 at the district health authority level , and they were mostly below 0.05 at the postal code sector level . At the household level , many ICCs were in the range of 0.0 - 0.3 . These data may provide useful information for the design of epidemiologic studies in which the units sample d or allocated range in size from households to large administrative areas Abstract Objective To investigate whether a form of advance agreement for people with severe mental illness can reduce the use of inpatient services and compulsory admission or treatment . Design Single blind r and omised controlled trial , with r and omisation of individual patients . The investigator was blind to allocation . Setting Eight community mental health teams in southern Engl and . Participants 160 people with an operational diagnosis of psychotic illness or non-psychotic bipolar disorder who had experienced a hospital admission within the previous two years . Intervention The joint crisis plan was formulated by the patient , care coordinator , psychiatrist , and project worker and contained contact information , details of mental and physical illnesses , treatments , indicators for relapse , and advance statements of preferences for care in the event of future relapse . Main outcome measures Admission to hospital , bed days , and use of the Mental Health Act over 15 month follow up . Results Use of the Mental Health Act was significantly reduced for the intervention group , 13 % ( 10/80 ) of whom experienced compulsory admission or treatment compared with 27 % ( 21/80 ) of the control group ( risk ratio 0.48 , 95 % confidence interval 0 
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Similarly , no significant differences were found for compliance with treatment , self harm or number of arrests .