Crisis plans and psychiatric advance directives are the structured documents that capture, during stable periods, what the patient wants to happen during future crises. The patient's well-version is the best resource for their unwell version; planning ahead while clear-headed produces better outcomes than improvising during a crisis.
Crisis plans are informal documents collaboratively built between clinician and patient during stable periods. Specific to the patient: early warning signs they recognize in themselves, what has worked for them before, who they want involved, what medications they want to try first, what they want to avoid, what setting they prefer for care during crisis, who can speak for them when they can't speak for themselves. The plan is for the patient's next crisis; the work happens now.
Psychiatric advance directives (PADs) are formal legal documents that may carry weight during involuntary care decisions, depending on jurisdiction. The patient specifies in advance what treatment they want or don't want during periods of incapacity. PADs are particularly valuable for patients with recurrent severe mental illness — bipolar I, schizophrenia, severe recurrent depression with suicidality — where the future crisis is likely and the patient has clear preferences.
Build during stable periods. The bipolar patient who has been well for 2 years is the right candidate to build a crisis plan about their next episode. "Let's use this stable time to plan for the next episode — even though we hope there isn't one. What did you learn from prior episodes?" Patient often has substantial insight when well that's not accessible when unwell.
Honor the plan in the next crisis. When the patient becomes manic and refuses lithium, the prior crisis plan that says "I want lithium even if I refuse during episodes" matters. Both ethically and sometimes legally, the well-version's preferences carry weight against the unwell-version's refusals. Document the prior plan in the chart so it's accessible during the crisis.
Update after each crisis. What was learned? What worked? What didn't? Revise the plan based on the latest episode while it's fresh. The plan evolves over years and episodes.
Share the plan with family, with the receiving clinicians, sometimes with crisis services. The plan in the chart that no one accesses during the crisis doesn't help; the plan that's accessible to the people involved in the next crisis does.