Involuntary admissions for the treatment of mental disorders affect 10% of mental health services users. Psychiatric Advance Directives (PADs) are documents that allow users notifying treatment preferences for crisis relapses. PADs have been experienced in several countries to improve users’ empowerment and reduce involuntary treatment. However, PADs take-up rate remains low and its effectiveness inconsistently evaluated. A hypothesis is that PADs should be considered as a process including its completion, registration, and honouring.

A Multi-Criteria Stakeholders’ Survey was carried out to understand what an optimal PAD process should be, and what the main hurdles are in implementing it.

102 Belgian stakeholders were selected among users and non-users groups, and face-to-face interviewed. Each interviewee scored 20 different options in designing, completing, registering and honouring a PAD. Four criteria were assessed: patient's autonomy, therapeutic relationship, mental care continuity and feasibility.

Overall, the PAD options aiming at improving access to the document and honouring statements received lower scores than options aiming its design or completion. Therapeutic relationship was a more important criterion than autonomy for the non-users than for the users group (p = 0.03). Options with the highest scores emphasized that PADs should be requested by the user, drafted in an outpatient setting, include de-escalating methods, justify treatment preferences, allow appointing a surrogate decision-maker, and need health providers training or a case-coordinator to be honoured.

PAD access and honouring are problematic steps of the process and should be developed to improve the use of PADs and its possible effectiveness