Importance Reducing the use of coercion in mental health care is crucial from a human rights and public health perspective. Psychiatric advance directives (PADs) are promising tools that may reduce compulsory admissions. Assessments of PADs have included facilitation by health care agents but not facilitation by peer workers. Objective To determine the efficacy of PADs facilitated by peer workers (PW-PAD) in people with mental disorders. Design, Setting, and Participants A multicenter randomized clinical trial was conducted in 7 French mental health facilities. Adults with a DSM-5 diagnosis of schizophrenia, bipolar I disorder, or schizoaffective disorder who had a compulsory admission in the past 12 months and the capacity to consent were enrolled between January 2019 and June 2020 and followed up for 12 months. Interventions The PW-PAD group was invited to fill out a PAD form and meet a peer worker who was trained to assist in completing and sharing the form with relatives and psychiatrists. Main Outcomes and Measures The primary outcome was the rate of compulsory admission at 12 months after randomization. The overall psychiatric admission rate, therapeutic alliance, quality of life, mental health symptoms, empowerment, and recovery outcomes were also investigated. Results Among 394 allocated participants (median age, 39 years; 39.3% female; 45% with schizophrenia, 36% bipolar I disorder, and 19% schizoaffective disorder), 196 were assigned to the PW-PAD group and 198 to the control group. In the PW-PAD group, 27.0% had compulsory admissions compared with 39.9% in the control group (risk difference, -0.13; 95% CI, -0.22 to -0.04; P = .007). No significant differences were found in the rate of overall admissions, therapeutic alliance score, and quality of life. Participants in the PW-PAD group exhibited fewer symptoms (effect size, -0.20; 95% CI, -0.40 to 0.00), greater empowerment (effect size, 0.30; 95% CI, 0.10 to 0.50), and a higher recovery score (effect size, 0.44; 95% CI, 0.24 to 0.65), compared with those in the control group. Conclusions and Relevance Peer worker-facilitated PADs are effective in decreasing compulsory hospital admissions and increasing some mental health outcomes (self-perceived symptoms, empowerment, and recovery). Involving peer workers in the completion of PADs supports the current shift of mental health care from substitute decision-making to supported decision-making. Trial Registration ClinicalTrials.gov Identifier: NCT03630822.

中文翻译：

---

同行工作者促进的精神病学预先指示对精神疾病患者强制入院的影响：一项随机临床试验。

重要性 从人权和公共卫生的角度来看，减少在精神卫生保健中使用强制手段至关重要。精神病学预先指示 (PAD) 是很有前途的工具，可以减少强制入院。对 PAD 的评估包括卫生保健人员的协助，但不包括同行工作人员的协助。目的 确定由同伴工作者促进的 PAD (PW-PAD) 在精神障碍患者中的​​疗效。设计、设置和参与者 一项多中心随机临床试验在 7 个法国精神卫生机构进行。在 2019 年 1 月至 2020 年 6 月期间招募了 DSM-5 诊断为精神分裂症、双相 I 型障碍或分裂情感障碍且在过去 12 个月内强制入院且有同意能力的成年人，并随访 12 个月。干预 PW-PAD 小组被邀请填写一份 PAD 表格，并会见一位受过培训的同伴工作人员，以协助完成表格并与亲属和精神科医生分享。主要结果和措施 主要结果是随机分组后 12 个月的强制入院率。还调查了整体精神病学入院率、治疗联盟、生活质量、心理健康症状、赋权和康复结果。结果 在 394 名参与者（中位年龄 39 岁；39.3% 女性；45% 患有精神分裂症，36% 躁郁症 I 型障碍和 19% 分裂情感障碍）中，196 人被分配到 PW-PAD 组，198 人被分配到对照组。在 PW-PAD 组中，27.0% 强制入院，而对照组为 39.9%（风险差异，-0.13；95% CI，-0.22 至 -0.04；P = .007）。在总体入院率、治疗联盟评分和生活质量方面没有发现显着差异。PW-PAD 组的参与者表现出更少的症状（效应大小，-0.20；95% CI，-0.40 至 0.00），更大的授权（效应大小，0.30；95% CI，0.10 至 0.50）和更高的恢复分数（与对照组相比，效应量，0.44；95% CI，0.24 到 0.65）。结论和相关性 由同行工作人员协助的 PAD 在减少强制住院和增加一些心理健康结果（自我感知症状、赋权和康复）方面是有效的。让同侪工作者参与完成 PAD 支持当前的精神卫生保健从替代决策转向支持决策。试验注册 ClinicalTrials.gov 标识符：NCT03630822。