Magnitude of impairment in decisional capacity in people with schizophrenia compared to normal subjects: an overview

Informed consent in the psychosis prodrome: ethical, procedural and cultural considerations

Research focused on the prodromal period prior to the onset of psychosis is essential for the further development of strategies for early detection, early intervention, and disease pre-emption. Such efforts necessarily require the enrollment of individuals who are at risk of psychosis but have not yet developed a psychotic illness into research and treatment protocols. This work is becoming increasingly internationalized, which warrants special consideration of cultural differences in conceptualization of mental illness and international differences in health care practices and rights regarding research participation. The process of identifying and requesting informed consent from individuals at elevated risk for psychosis requires thoughtful communication about illness risk and often involves the participation of family members. Empirical studies of risk reasoning and decisional capacity in young people and individuals with psychosis suggest that most individuals who are at-risk for psychosis can adequately provide informed consent; however ongoing improvements to tools and procedures are important to ensure that this work proceeds with maximal consideration of relevant ethical issues. This review provides a discussion of these issues in the context of international research efforts.

[Schizophrenia and informed consent to research]

CONTEXT

Informed consent to research remains a complex issue, while sometimes staying difficult to obtain, even in the general population. This problem may be maximized with patients suffering from schizophrenia.

OBJECTIVE

This paper summarizes available data in the literature about informed consent for research involving patients suffering from schizophrenia.

METHOD

Medline and Google Scholar searches were conducted using the following MESH terms: schizophrenia, informed consent and research.

RESULTS

Studies using dedicated standardized scales (e.g. MacCAT-CR) revealed a decrease in the capacity to consent of patients with schizophrenia when compared with healthy individuals. Keeping in mind that schizophrenia is an heterogeneous disorder, patients with the lowest insight as well as those with the most severe cognitive symptoms appeared more impaired in their capacity to consent. Such a poor capacity to understand and consent to trials was shown linked with alterations in decision-making. For these specific patients, interventions may be set up to increase their capacity to consent. Various strategies were proposed: enhanced consent forms, extended discussion, test/feedback method or multimedia interventions. Among them, interventions relying on communication and the growing field of information technologies (e.g. web-based tools) seem promising. Finally, associations grouping families and patients (like the French Association UNAFAM) may facilitate the involvement of patients in research programs with safer conditions.

CONCLUSION

Patients suffering from schizophrenia appear able to consent to research programs when suitable interventions are proposed. Further studies are now needed to optimize and individualize such interventions.

Do investigators understand ethically-important perspectives of clinical research participants?: a 'piggy-back' study of attunement and alignment in serious illness research

OBJECTIVE

The authors sought to compare investigators' predictions of clinical research participants' attitudes regarding ethically-important considerations in serious illness research with attitudes expressed by participants ("attunement"), to compare the personal attitudes of investigators and clinical research participants ("alignment"), and to explore the association between views expressed and covariates.

METHOD

The authors queried clinical research participants with either physical or mental illness (n=100) and faculty investigators conducting the clinical research protocols in which these participants were enrolled (n=77). Outcomes included attitudes regarding importance of medical research, attributes of seriously ill people in the research situation, and influences on enrollment decisions by seriously ill people. Generalized estimating equations and linear regression models were used.

RESULTS

Investigators underestimated the importance of research about physical illness, mental illness, and healthy people to participants (βPI=0.59, 95% CI [0.36, 0.83]; βMI=0.60, 95% CI [0.27, 0.92]; βH=0.93, 95% CI [0.57, 1.29]). Investigators incorrectly predicted that participants would assess seriously ill people as more vulnerable in the research situation than participants did (β=-0.68, 95% CI [-1.11, -0.25]). Investigators and participants were aligned on the importance of illness research. Participants expressed greater agreement than investigators regarding the influences of ill individuals indicative of will and cognition in their enrollment decisions (β=0.69, 95% CI [0.25, 1.13]).

CONCLUSIONS

Investigators are attuned to and aligned with research participants in many, but not all, respects. Investigators may bring a protective bias in their predictions of the vulnerabilities of ill volunteers.

Stigma in patients with schizophrenia receiving community mental health care: a review of qualitative studies

PURPOSE

The aim of this review is to identify consistent themes among the qualitative literature on stigma as experienced by patients with schizophrenia receiving community mental health care. With the treatment focus of schizophrenia nowadays shifting more and more towards community-based mental health care, professionals need to be aware of the increased vulnerability of their clients in their social environment as a result of stigma towards their disease. In-depth knowledge on stigma is critical in order to offer a dignifying community mental health care.

METHODS

A systematic search of the qualitative literature in Web of Science, PubMed, PsycINFO and Francis was performed to review the subjective experiences and ideas on stigma in outpatients with schizophrenia.

RESULTS

Three major themes were identified in 18 studies and need to be taken into consideration when implementing an adequate community mental health care: (i) the continuing existence of stigma inherent in the health care setting, (ii) the importance of relational aspects of stigma encounters in daily life and (iii) the significance of the behavioural aspects related to previous stigma experiences and beliefs among patients.

CONCLUSIONS

Despite much effort in community treatment, patients still experience stigma and discrimination. Community mental health care professionals should not only be aware of structural problems in mental health care, but should also pay considerable attention towards the relational and behavioural aspects in their clients' life concerning stigma. Furthermore, they have the crucial role in the community to raise awareness about stigma in order to increase their clients' acceptance in society.

Assessing capacity in psychiatric patients with acute medical illness who refuse care

Three cases are presented that demonstrate the difficulty of assessing medical decision-making capacity in patients with psychiatric illness who are refusing care. Health professionals often assess capacity differently in practice. Provided their patients have some understanding of their illness and have some plans for meeting basic needs, psychiatrists are often inclined to give patients the freedom to refuse care even if they do not exhibit a full understanding of the medical facts of their case and why they are refusing it. Adult medicine physicians, in contrast, are inclined to require patients to state a more complete understanding of the benefits and burdens of evaluation and treatment before allowing them to refuse care when their refusals might result in adverse medical outcomes. The 3 cases exemplify the tension between these approaches and highlight the role of hospital ethics consultation in addressing this conflict.

Validation of Chinese version of the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) in patients with schizophrenia spectrum disorders

There is a lack of validated instruments assessing the decision-making capacity to consent to clinical research of patients with schizophrenia spectrum disorders who speak Chinese. This study aimed to determine the validity and reliability of the Chinese version of MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). The MacCAT-CR using a hypothetical study, the Positive and Negative Syndrome Scale (PANSS), the Mini-Mental State Examination (MMSE) assessed 139 patients with schizophrenia or schizoaffective disorder. The Cronbach's alpha coefficient was 0.74. The intra-class coefficients for understanding, appreciation, and reasoning scores ranged from 0.53 to 0.81. Regarding validity, the understanding, appreciation and reasoning scores were negatively correlated with the PANSS (r ranged from -0.27 to -0.33), and the negative subscale score (r ranged from -0.31 to -0.37) as well as positively correlated with the MMSE (r ranged from 0.26 to 0.43). All pvalues were less than 0.01. The factor analysis explained 57.6 % of the total variance; specifically, Components 1 and 2 contributed 44.5% and 13.1 % of the variance respectively. These findings indicate that the Chinese version of the MacCAT-CR is a reliable and valid instrument to assess the decision-making capacity to consent to clinical research of patients with schizophrenia spectrum disorders.

Changes in capacity to consent over time in patients involved in psychiatric research

BACKGROUND

Informed consent is a key element of ethical clinical research. Patients with serious mental illness may be at risk for impaired consent capacity. Corrective feedback improves within-session comprehension of consent-relevant information, but little is known about the trajectory of patients' comprehension after the initial enrolment session.

AIMS

To examine whether within-session gains in understanding after feedback were maintained between study visits and to examine stability of decisional capacity over time.

METHOD

This was a longitudinal, within-participants comparison of decisional capacity assessed at baseline, 1 week, 3 months, 12 months and 24 months in 161 people with schizophrenia or bipolar disorder.

RESULTS

Within-session gains from corrective feedback generally dissipated over each follow-up interval. Decisional capacity showed a general pattern of stability, but there was significant between-participant heterogeneity. Better neuropsychological performance was associated with better decisional capacity across time points. Positive symptoms of schizophrenia did not predict any aspects of decisional capacity, but general psychopathology, negative symptoms and depression evidenced some modest associations with certain subdomains of decisional capacity.

CONCLUSIONS

Informed consent may be most effectively construed as an ongoing dialogue with participants at each study visit.

Capacity of forensic patients to consent to treatment

OBJECTIVE

Lack of capacity to consent to psychiatric treatment has been promoted as a better basis for compulsion than mental disorder plus risk of harm. Previous research has examined how that legal change would affect acutely unwell inpatients. There is little research on forensic patients. This research aimed to assess capacity to consent in forensic patients at different stages of recovery and to consider the implications of respecting their competent treatment decisions.

METHOD

Capacity to consent was assessed in a cross-sectional sample of 109 forensic patients both in hospital and in community settings.

RESULTS

The majority of participants (67.6%) had treatment-related decision-making capacity. Very few patients with capacity refused treatment.

CONCLUSIONS

Change to a capacity-based legal approach may alter treatment for some forensic patients but would not necessarily increase risk of harm to others. The implications for release decisions are less clear.

The Greek version of the MacArthur competence assessment tool for treatment: reliability and validity. Evaluation of capacity for treatment decisions in Greek psychiatric patients

BACKGROUND

Patients' informed consent prior to treatment initiation is an essential component of contemporary clinical practice, but sometimes, patients lack decision-making capacity for treatment. Such capacity can be reliably assessed with standardized tools used, and the MacArthur competence assessment tool for treatment (MacCAT-T) is one of the most widely used instruments.

METHODS

The objective of this study was to translate the MacCAT-T into Greek and evaluate the Greek version's reliability and validity in psychiatric patients. Thirty-nine psychiatric inpatients were examined with the MacCAT-T, and results showed an excellent inter-rater reliability.

RESULTS

Intraclass correlations ranged from 0.93 to 1 for the individual items of the tool. Severity of psychopathology was negatively correlated with reasoning, appreciation, and expressing a choice (Pearson's r 0.36, 0.539, and 0.338, respectively), but there were no associations with demographic characteristics of the patients. Of the five factors derived from the brief psychiatric rating scale, anergia was significantly correlated with appreciation, reasoning, and expressing a choice (Pearson's r 0.46, 0.45, and 0.37, respectively).

CONCLUSIONS

The Greek version of the MacCAT-T is a reliable and valid instrument that can provide a standardized measure for assessing treatment decision capacity in Greek psychiatric patients and can be used for evaluation in the clinical practice.

Cognitive insight as an indicator of competence to consent to treatment in schizophrenia

The processes underlying the ability to make decisions about recommended treatments remain poorly understood in schizophrenia. The aim of this study was to explore the relationships between capacity to consent to medication and cognitive biases in 60 schizophrenia patients. Main measures included the MacArthur Competence Assessment tool for Treatment (MacCAT-T) and the Beck Cognitive Insight Scale (BCIS). After Bonferroni's correction for multiple correlations, the Self-Reflectiveness dimension of the BCIS was significantly associated with the dimension "Reasoning" of the MacCAT-T. Cognitive therapy, by enhancing patients' Self-Reflectiveness and considering alternative explanations, could lead to better capacity to consent to treatment in schizophrenia.

The Relationship Between Executive Functions and Capacity to Consent to Treatment in Acute Psychiatric Hospitalization

Despite the acknowledged influence of cognition on patients' capacity to consent to treatment, the specific neuropsychological domains involved remain elusive, as does the role of executive functions. We investigated possible associations between executive functions and decisional capacity in a sample of acute psychiatric inpatients. Patients were recruited and evaluated through the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the 24-item Brief Psychiatric Rating Scale (BPRS), the Mini-Mental State Examination (MMSE), and the Wisconsin Card Sorting Test (WCST). Patients with poor executive functioning performed worse in MacCAT understanding, appreciation, and expression of a choice, compared with good performers. These findings point to the importance of cognition in decisional capacity processes. In addition, the strong association found between learning abilities and informed consent decision-making provide empirical evidence indicating possible cognitive enhancement strategies that may improve psychiatric patients' competency.

Restoring balance: a consensus statement on the protection of vulnerable research participants

A diverse panel convened in June 2011 to explore a dilemma in human research: some traits may make individuals or communities particularly vulnerable to a variety of harms in research; however, well-intended efforts to protect these vulnerable individuals and communities from harm may actually generate a series of new harms. We have presented a consensus statement forged by the panel through discussion during a 2-day meeting and the article-writing process. We have identified practical problems that sometimes arise in connection with providing additional safeguards for groups labeled as vulnerable and offered recommendations on how we might better balance concerns for protection with concerns for justice and participant autonomy.

Delirium and decisional incapacity in veterans with schizophrenia and medical illness

OBJECTIVE

The objective was to examine the characteristics of Veterans with schizophrenia admitted for nonpsychiatric hospitalizations.

METHOD

We conducted a review of the electronic medical record and data warehouse downloads of Veterans with schizophrenia admitted to nonpsychiatric services of a large, academic Veterans Affairs hospital between 2004 and 2009 on whom psychiatry was consulted.

RESULTS

Seventy-four veterans were admitted 89 times. Their mean age was 62 years. Among these veterans, the most common reasons for nonpsychiatric admission were infection, cardiac disease or altered mental status. Thirty-three percent of consultations were for patients who required intensive care. Consultation was requested most frequently for assessing psychotropic medication, decision-making capacity or altered mental status, or for assistance with behavioral problems. Thirty-seven percent of patients were diagnosed with delirium, and 42% lacked decision-making capacity, mostly secondary to delirium. Twenty-seven percent of patients died during the study period.

CONCLUSION

In an aging cohort of Veterans with schizophrenia, a substantial proportion of patients developed delirium, lost decision-making capacity and required intensive care during nonpsychiatric hospital admission.

Picturing neuroscience research through a human rights lens: imaging first-episode schizophrenic treatment-naive individuals

In this paper we examine imaging research involving first-episode schizophrenic treatment-naive individuals (FESTNIs) through a legal human rights lens; in particular, the lens of the Additional Protocol to the Convention on Human Rights and Biomedicine Concerning Biomedical Research. We identify a number of ethical and legal hot spots highlighted by the Protocol, and offer a series of recommendations designed to ensure the human rights compatibility of this research. Subsequently, we argue that the lack of reporting on design elements related to ethical concerns frustrates commitments at the heart of the human rights approach, namely, transparency and openness to international scrutiny. To redress this problem, we introduce two norms for the first time: ethical transparency, and ethical reproducibility. When concluding, we offer a set of reporting guidelines designed to operationalize these norms in the context of imaging research involving FESTNIs. Though we will not make this case here, we believe that parallel reporting guidelines should be incorporated into other areas of research involving human subjects.

Addressing non-adherence to antipsychotic medication: a harm-reduction approach

This paper discusses the evidence base for interventions addressing non-adherence to prescribed antipsychotics. A case study approach is used, and the extent to which adherence improvement interventions might be used in collaboration with a specific patient is considered. The principles and application of harm-reduction philosophy in mental health are presented in a planned non-adherence harm-reduction intervention. This intervention aims to acknowledge the patient's ability to choose and learn from experience and to reduce the potential harm of antipsychotic withdrawal. The intervention evaluation method is outlined.

Informed consent: a critical part of modern medical research

Informed consent is one of the great puzzles of modern medical research and practice. As Professor Henderson has argued in her article, there is ample reason to be concerned that many, and maybe all, of the goals announced for informed consent law and ethics have not been reached. In this article, I will review the goals that theorists and judges have assigned to the doctrine and discuss some of the evidence concerning the difficulties of meeting those goals. Finally, I will suggest some of the reasons that might account for our continued commitment to informed consent despite its difficulties.

Voluntary consent in correctional settings: do offenders feel coerced to participate in research?

A major ethical concern in research with criminal offenders is the potential for abuse due to coercive influences that may adversely affect offenders' capacity to give voluntary consent to participate in research conducted in correctional settings. Despite this concern, to date there have been almost no systematic scientific investigations of the extent to which offenders themselves perceive that coercion occurs in these settings or that it is likely to influence their decisions about research participation. In a sample of over 600 ethnically diverse men and women recruited from various prisons and community corrections facilities in Texas and Florida, we used a vignette-based survey concerning a hypothetical research project to measure and compare offenders' global perceptions of coercive processes, as well as the differential salience and perceived coercive influence of specific factors (e.g., coercion by other inmates, inducements from staff). Somewhat surprisingly, across multiple outcome measures our participants on average reported relatively little in the way of significant coercive influences on their capacity to make voluntary decisions concerning research participation. Implications and directions for future research on coercive influences in offender research are discussed.

Barriers to participation in a patient satisfaction survey: who are we missing?

BACKGROUND

A common weakness of patient satisfaction surveys is a suboptimal participation rate. Some patients may be unable to participate, because of language barriers, physical limitations, or mental problems. As the role of these barriers is poorly understood, we aimed to identify patient characteristics that are associated with non-participation in a patient satisfaction survey.

METHODOLOGY

At the University Hospitals of Geneva, Switzerland, a patient satisfaction survey is regularly conducted among all adult patients hospitalized for >24 hours on a one-month period in the departments of internal medicine, geriatrics, surgery, neurosciences, psychiatry, and gynaecology-obstetrics. In order to assess the factors associated with non-participation to the patient satisfaction survey, a case-control study was conducted among patients selected for the 2005 survey. Cases (non respondents, n = 195) and controls (respondents, n = 205) were randomly selected from the satisfaction survey, and information about potential barriers to participation was abstracted in a blinded fashion from the patients' medical and nursing charts.

PRINCIPAL FINDINGS

Non-participation in the satisfaction survey was independently associated with the presence of a language barrier (odds ratio [OR] 4.53, 95% confidence interval [CI95%]: 2.14-9.59), substance abuse (OR 3.75, CI95%: 1.97-7.14), cognitive limitations (OR 3.72, CI95%: 1.64-8.42), a psychiatric diagnosis (OR 1.99, CI95%: 1.23-3.23) and a sight deficiency (OR 2.07, CI95%: 0.98-4.36). The odds ratio for non-participation increased gradually with the number of predictors.

CONCLUSIONS

Five barriers to non-participation in a mail survey were identified. Gathering patient feedback through mailed surveys may lead to an under-representation of some patient subgroups.

Decisional capacity and consent for schizophrenia research

Background

Despite substantial research on overall decision-making capacity (DMC) levels in schizophrenia, factors causing individuals to make errors during decision-making regarding research participation or treatment are relatively unknown.

Methods

We examined the responses of 84 middle-aged and older patients with schizophrenia or schizoaffective disorder on a structured DMC measure—the MacArthur Competence Assessment Tool for Clinical Research—to determine the frequency and apparent cause of patients’ errors.

Results

Most errors were due to difficulty recalling the disclosed information (seen in 65.5% of patients), particularly the study’s procedures, potential risks/discomforts, and purpose. Errors attributable to concrete thinking, thought disorder or other psychotic symptoms, or perceived coercion were rarer.

Conclusions

Informed consent procedures might be improved for this population by providing information in a way that facilitates learning and memory, such as iterative disclosure of the information, corrective feedback, and emphasis of key points (e.g., the study’s purpose, procedures, and potential risks).

Do physicians' recommendations pull patients away from their preferred treatment options?

CONTEXT AND OBJECTIVE

Shared decision making is especially advocated for preference-sensitive decisions. We investigated whether physicians' recommendations pull patients away from their preferred treatment option when making a preference-sensitive decision. DESIGN, PARTICIPANTS AND METHODS: Inpatients (N = 102 with schizophrenia, N = 101 with multiple sclerosis) were presented with a hypothetical scenario (the choice between two drugs). They were first asked about their preferences concerning the two drugs and then they received a (fictitious) clinician's recommendation that was contrary to their preferences. Subsequently they made a final choice between the two drugs.

MAIN OUTCOME MEASURES

The main outcome measure was whether the patient followed the physician's advice in the hypothetical scenario. Thereby patient's (pre-recommendation) preferences served as a baseline.

RESULTS

In the decision scenario, about 48% of the patients with schizophrenia and 26% of the patients with multiple sclerosis followed the advice of their physician and thus chose the treatment option that went against their initial preferences. Patients who followed their physician's advice were less satisfied with their decision than patients not following their physician's advice (schizophrenia: t = 2.61, P = 0.01; multiple sclerosis: t = 2.67, P = 0.009).

DISCUSSION AND CONCLUSIONS

When sharing decisions with patients, physicians should be aware that their advice might influence patients' decisions away from their preferred treatment option. They should encourage their patients to identify their own preferences and help to find the treatment option most consistent with them.

Putting the "evidence" in evidence-based practice: meeting research challenges in community psychiatric settings

Every psychiatric client deserves access to treatments that have evidence of efficacy, but in psychiatric nursing, this evidence remains sparse. To address this deficit, researchers must commit to conducting high quality, community-based psychiatric nursing intervention investigations. In service of this goal, the authors draw upon their research experiences in community psychiatric settings to suggest options for overcoming system-, clinician-, and client-related research barriers in community psychiatric settings.

Ethical Issues in Deep Brain Stimulation Research for Treatment-Resistant Depression: Focus on Risk and Consent

Deep brain stimulation (DBS) is currently in pivotal trials as an intervention for treatment-resistant depression (TRD). Although offering hope for TRD, DBS also provokes ethical concerns-particularly about decision-making capacity of people with depression-among bioethicists, investigators, institutional review boards, and the public. Here, we examine this critical issue of informed consent for DBS research using available evidence regarding decision-making capacity and depression. Further, we explore the implications of the nature of TRD as well as that of the intervention (invasive brain surgery) for informed consent. Based on these analyses, we argue that additional safeguards specific to DBS research for TRD, beyond those that might be used in any higher risk study, are not supported by available empirical evidence. We nevertheless underscore the limited data on such invasive procedures in severely ill psychiatric patients and advocate a research agenda for the systematic study of ethical issues raised by these research endeavors.

Ethics in Psychiatric Research: A Review of 25 Years of NIH-funded Empirical Research Projects

BACKGROUND: This paper reviews the past 25 years of empirical research funded by the National Institutes of Health (NIH) on matters of ethics in psychiatric research. METHODS: Using the NIH RePORTER and Medline databases, we identified 43 grants and 77 publications that involved the empirical study of a matter of ethics in research involving mental health service users. RESULTS: These articles provide original and useful information on important topics, most especially the capacity to consent and the voluntariness of consent. For example, participants who share a diagnosis vary widely in levels of cognitive impairment that correlate with decisional capacity, and capacity to consent can be enhanced easily using iterative consent processes. Few articles address matters of justice or benefits in research, particularly from the perspectives of participants. No articles address matters of privacy, confidentiality, or researcher professionalism. CONCLUSIONS: Despite the usefulness of data from the studies conducted to date, current research on research ethics in psychiatry does not adequately address the concerns of service users as expressed in recent publications.

Free will and psychiatric assessments of criminal responsibility: a parallel with informed consent

In some criminal cases a forensic psychiatrist is asked to make an assessment of the state of mind of the defendant at the time of the legally relevant act. A considerable number of people seem to hold that the basis for this assessment is that free will is required for legal responsibility, and that mental disorders can compromise free will. In fact, because of the alleged relationship between the forensic assessment and free will, researchers in forensic psychiatry also consider the complicated metaphysical discussions on free will relevant to the assessment. At the same time, there is concern about the lack of advancement with respect to clarifying the nature of the forensic assessment. In this paper I argue that, even if free will is considered relevant, there may be no need for forensic researchers to engage into metaphysical discussions on free will in order to make significant progress. I will do so, drawing a parallel between the assessment of criminal responsibility on the one hand, and the medical practice of obtaining informed consent on the other. I argue that also with respect to informed consent, free will is considered relevant, or even crucial. This is the parallel. Yet, researchers on informed consent have not entered into metaphysical debates on free will. Meanwhile, research on informed consent has made significant progress. Based on the parallel with respect to free will, and the differences with respect to research, I conclude that researchers on forensic assessment may not have to engage into metaphysical discussions on free will in order to advance our understanding of this psychiatric practice.

The investigator and the IRB: a survey of depression and schizophrenia researchers

Despite the integral part Institutional Review Boards (IRBs) play in U.S. research, research on IRBs is lacking. This is especially true in the area of mental health investigator-IRB interactions. It was hypothesized that schizophrenia researchers would have a different experience with IRBs as compared to depression researchers. This would include longer turn-around time and fewer protocols approved on first submission. It was also thought that schizophrenia researchers would be more hesitant to submit ethically complex protocols for IRB review. 396 NIH-funded schizophrenia and depression investigators were invited to participate in a survey study on IRBs. 108 usable responses were returned, 45 of which were from schizophrenia researchers. Schizophrenia researchers were significantly less likely to submit ethically complex protocols for IRB review than depression researchers even when controlling for academic rank, years of research experience, type of research done, and the need to submit to multiple IRBs. However, there was no significant difference between researcher groups in IRB review turn-around time or initial approval rates. As a group, respondents found IRB submission paperwork burdensome but necessary and were almost evenly split as to whether IRB comments were helpful (54.8%) or not (45.2%). Time to initial review was 3 weeks or longer for most respondents. 94.4% agreed IRBs should enforce subject privacy and 68.2% agreed they should monitor conflict of interest, but only 37.% agreed IRBs should review study design. Conclusions are that 1. the population studied may have profound impacts on the type of protocols submitted to IRBs even within the field of mental health, 2. IRBs may not draw as large a distinction between depression and schizophrenia protocols as researchers believe, and 3. facilitating IRB review by eliminating evaluation of design may be possible if the protocol has already been vetted by a credible funding agency (such as the U.S. National Institutes of Health).

Informed consent to research in persons with schizophrenia spectrum disorders

This manuscript describes the responses and correlates of outpatients with schizophrenia spectrum disorders to a tool designed to measure comprehension before obtaining informed consent for research participation. We used the Evaluation to Sign Consent form to document comprehension in 100 outpatients as part of their consent to participate in an ongoing study of an exercise intervention. The findings suggest that using this form is a feasible and acceptable approach to documenting comprehension of research procedures prior to obtaining informed consent. Age 49 years and older and the receipt of intramuscular antipsychotic medication predicted the need for additional assistance to complete the Evaluation to Sign Consent form successfully (chi(2) = 8.29, P = 0.016). Nurse researchers should consider documenting comprehension with this tool owing to its availability, time efficiency and utility.

Assessment of the capacity to express informed consent for organ donation in patients with schizophrenia

In Italy, the "silent-consent" principle of donor's willingness regulates organ donation for postmortem transplantation, but civil incompetence excludes it. We investigated decisional capacity for organ donation for transplantation of 30 controls and 30 nonincompetent patients with schizophrenia as related to clinical symptoms, cognition, and functioning. Assessments were carried out through the Competence for Donation Assessment Scale (CDAS), Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms, Life Skills Profile (LSP), Raven's Colored Progressive Matrices (RCPM), Wisconsin Card Sorting Test, Rey RI, Rey RD, and Visual Search. Patients and controls differed on the CDAS Understanding and Choice Expression areas. Patients showed significant inverse bivariate correlations between CDAS Understanding and scores on total BPRS, LSP self-care scale, and RCPM cognitive test. Our results show that decisional capacity for participating in research does not predict decisional capacity for postmortem organ donation in patients with schizophrenic or schizoaffective psychosis; hence, before judging consent for donation, patients must be provided with enhanced information to better understand this delicate issue.

What is neuroethics? Empirical and theoretical neuroethics

PURPOSE OF REVIEW

Neuroethics is a recently emerging field that deals with predominantly empirical and practical issues of ethics in neuroscience. In contrast, theoretical and methodological considerations have rather been neglected and thus what may be called theoretical neuroethics.

RECENT FINDINGS

The review focuses on informed consent and moral judgment as examples of empirical neuroethics and norm-fact circularity and method-based neuroethics as issues of a theoretical neuroethics.

SUMMARY

It is argued that we need to consider theoretical and methodological issues in order to develop neuroethics as a distinct discipline, which as such can be distinguished from both philosophy/ethics and neuroscience.

Multimedia consent for research in people with schizophrenia and normal subjects: a randomized controlled trial

Limitations of printed, text-based, consent forms have long been documented and may be particularly problematic for persons at risk for impaired decision-making capacity, such as those with schizophrenia. We conducted a randomized controlled comparison of the effectiveness of a multimedia vs routine consent procedure (augmented with a 10-minute control video presentation) as a means of enhancing comprehension among 128 middle-aged and older persons with schizophrenia and 60 healthy comparison subjects. The primary outcome measure was manifest decisional capacity (understanding, appreciation, reasoning, and expression of choice) for participation in a (hypothetical) clinical drug trial, as measured with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and the University of California San Diego (UCSD) Brief Assessment for Capacity to Consent (UBACC). The MacCAT-CR and UBACC were administered by research assistants kept blind to consent condition. Additional assessments included standardized measures of psychopathology and cognitive functioning. Relative to patients in the routine consent condition, schizophrenia patients receiving multimedia consent had significantly better scores on the UBACC and on the MacCAT-CR understanding and expression of choice subscales and were significantly more likely to be categorized as being capable to consent than those in the routine consent condition (as categorized with several previously established criteria). Among the healthy subjects, there were few significant effects of consent condition. These findings suggest that multimedia consent procedures may be a valuable consent aid that should be considered for use when enrolling participants at risk for impaired decisional capacity, particularly for complex and/or high-risk research protocols.

Competence to consent and insight in schizophrenia: is there an association? A pilot study

OBJECTIVE

The capacity to consent to treatment or research of patients with severe mental disorders is the focus of important ethical and clinical debate. Many studies evaluate the links between clinical symptoms and the capacity to consent. The aim of this study was to explore the correlations existing between the competence to consent to treatment and the level of awareness of the disease (insight) in patients suffering from schizophrenia in a cross-sectional study.

METHOD

Participants included 60 outpatients meeting the criteria for a DSM-IV diagnosis of schizophrenia. Measures included the MacArthur Competence Assessment tool for Treatment (MacCAT-T), the Scale to Assess Unawareness of Mental Disorder (SUMD) and psychopathology rating scales including the Positive and Negative Syndrome Scale (PANSS).

RESULTS

The MacCAT-T dimension "Understanding" was found to be negatively correlated with negative and total PANSS scores but was not found to be correlated with any of the SUMD dimensions. However a systematic negative correlation was observed between the MacCAT-T "Appreciation" and "Reasoning" dimensions and the five SUMD dimensions. Finally, the MacCAT-T "Expressing a choice" dimension was found to be negatively correlated with two SUMD dimensions: "Having a mental disorder" and "consequences of the mental disorder".

CONCLUSIONS

These findings suggest an important correlation between the competence to consent to treatment and insight, a clinical variable currently assessed by clinicians. We hypothesized that this link could be mediated by cognitive impairments in schizophrenia. Emphasis should be placed on developing prospective studies comparing the courses of insight, cognitive disorders and capacity to consent in schizophrenia.

Shared decision making in antipsychotic management

The similar efficacies of currently available antipsychotic medications (other than clozapine) make them appropriate for preference-sensitive care; therefore, prescribing these medications is amenable to shared decision-making. In this conceptual article, we describe the current state of antipsychotic prescribing based on a review of the literature from recent landmark studies and updated prescribing guidelines. Recent literature and guidelines on schizophrenia treatment in the United States do not reveal strong endorsement of the idea of shared decision-making. We suggest methods for incorporating shared decision-making into antipsychotic prescribing in the future, with an emphasis on the use of information technology.

Examining informed consent in persons with schizophrenia

This descriptive study examined the responses of outpatients with schizophrenia to a tool designed to measure comprehension before obtaining informed consent to participate in a research study. We used the Evaluation to Sign Consent (ESC) form to document comprehension in 29 schizophrenia outpatients. Participants living in supervised housing were significantly more likely to require prompts than those living alone (chi(2) = 9.4, p = 0.024). Participants prescribed two antipsychotic medications were significantly more likely to require a prompt than those prescribed only one antipsychotic (chi(2) = 5.12, p = 0.023). Nurse researchers should consider documenting comprehension with the ESC due to its availability, time efficiency, and utility.

Emotional decision-making and its dissociable components in schizophrenia and schizoaffective disorder: a behavioural and MRI investigation

Cognitive decision-making is known to be deficient, but relatively less is known about emotional decision-making in schizophrenia. The Iowa gambling task (IGT) is considered a reliable probe of emotional decision-making and believed to reflect orbitofrontal cortex (OFC) function. The expectancy-valence model of IGT performance implicates three dissociable components, namely, attention to reward, memory for past, relative to recent, outcomes and impulsivity in emotional decision-making. We examined IGT performance, its three components, and their grey matter volume (GMV) correlates in 75 stable patients with schizophrenia, relative to 25 healthy individuals. Patients, relative to controls, showed impaired IGT performance and poor memory for past, relative to recent, outcomes. IGT performance correlated with GMV in the OFC in controls, but not patients. There were associations between (a) attention to reward and GMV in the frontal, temporal, parietal and striatal regions in controls, and in the temporal and thalamic regions in patients, (b) memory for past outcomes and GMV in the temporal region in controls, and the frontal and temporal regions in patients, and (c) low impulsivity and greater GMV in the frontal, temporal, posterior cingulate and occipital regions in controls, and in the frontal, temporal and posterior cingulate regions in patients. Most IGT-GMV associations were stronger in controls. It is concluded that (i) poor memory, rather than less attention to reward or impulsivity, contributes to IGT performance deficit, and (ii) the relationship of IGT performance and its components with GMVs especially in the frontal and temporal lobes is lost or attenuated in schizophrenia.

A direct comparison of research decision-making capacity: schizophrenia/schizoaffective, medically ill, and non-ill subjects

To characterize predictors of impairment in research decision-making capacity, we undertook a direct comparison of schizophrenia/schizoaffective (n=52), medically ill (diabetic; n=51), and non-ill (n=57) subjects. Scores on the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) were correlated with demographic variables and scores on the Positive and Negative Syndrome Scale (PANSS), Mini-Mental State Examination (MMSE), and Short-Form-36 (SF-36). Across diagnoses, cognitive capacity, physical functioning, and a diagnosis of mental illness had the greatest impact on decision-making capacity, with level of education also having an impact. 69-89% of schizophrenia/schizoaffective subjects attained MacCAT-CR subscale scores achieved by almost all comparison (98-100%) and medically ill (94-100%) subjects. Positive, negative, and general psychotic symptoms correlated with poorer scores. Prior research experience, number of queries used during interview, and emotional functioning also predicted MacCAT-CR scores. These data suggest that investigators and IRBs should consider a number of variables, many of which reach across diagnoses, as they decide which populations and individual subjects may require more intensive screening for decisional impairment or educational interventions to improve their abilities to make capable decisions about research participation.

Prevalence and correlates of adequate performance on a measure of abilities related to decisional capacity: differences among three standards for the MacCAT-CR in patients with schizophrenia

Despite the availability of structured decision-making capacity assessment tools, insufficient guidance exists for applying their results. Investigators often use cutpoints on these instruments to identify potential subjects in need of further assessment or education. Yet, information is lacking regarding the effects of different cutpoints on the proportion and characteristics of individuals categorized as possessing adequate or impaired decisional abilities for consent to research. To demonstrate the potential impact of different standards, we informed 91 individuals, aged 50 or older with a diagnosis of schizophrenia or schizoaffective disorder, about a hypothetical clinical trial, and assessed their decisional abilities with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). Three published MacCAT-CR-based standards were applied to participants' scores to examine the rates and correlates of categorical determinations of adequate performance. The three standards ranged in stringency: the most stringent incorporated cutpoints on all three of the major MacCAT-CR subscales (Understanding, Appreciation, and Reasoning); the other two standards required threshold performance only on the Understanding subscale. The most stringent standard resulted in a 57% rate of impaired performance; the intermediate standard, 19%; and the least stringent standard, 8%. Nearly half of the participants (n=45) were classified as having performed adequately by the least stringent standard yet inadequately by the most stringent. The majority of these 45 were impaired on the Appreciation subscale (n=9), Reasoning (n=15), or both (n=18). Cognitive functioning was correlated with performance status for the more stringent standards. These findings underscore the need for refinement of capacity assessment procedures and for improvements in the use of capacity assessment tools for screening purposes and to assist in categorical capacity determinations.

Relationship of individual cognitive abilities to specific components of decisional capacity among middle-aged and older patients with schizophrenia

Prior empirical studies suggest that cognitive impairment is the strongest predictor of capacity to consent to research among persons with schizophrenia. Yet, despite the frequency and importance of cognitive deficits and impaired decisional capacity in schizophrenia, the scope of neuropsychological testing in most published reports in this area has been relatively narrow. In the present study of 70 people with schizophrenia aged 40 to 70 years we evaluated decisional capacity with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). Participants were also evaluated with standardized rating scales of psychopathology and level of insight and with a comprehensive neuropsychological test battery that permitted evaluation of 7 specific cognitive abilities. Results showed that the strongest correlates of capacity (particularly, understanding and appreciation of disclosed information) were cognitive test scores, but there was little evidence of differential relationships between individual cognitive abilities and specific dimensions of capacity. Understanding was also correlated with severity of negative symptoms and of general psychopathology, but not with age, education, severity of positive or depressive symptoms, or level of insight. Understanding improved over successive presentations of consent-relevant information. The results suggest that age and diagnosis should not be viewed as determinants of decisional capacity; investigators should be alert to the presence of cognitive deficits, as well as negative symptoms. Also, an interactive dialogue between patient and investigator with repeated presentation of information is likely to aid understanding of disclosed information among patients with schizophrenia.

Decisional capacity in mental illness and substance use disorders: empirical database and policy implications

Debates on decisional capacity in people with mental illnesses or substance use disorders have tended to be heated. Yet, they are often based not on empirical data but on personal opinions and experiences. The empirical database in this area is quite limited, but has been growing in recent years. The following discussion focuses on relevant clinical investigations. We consider variations across and within different diagnoses, barriers to decision-making, methods for assessing capacity-interview versus instruments, choosing from among different capacity instruments, decisional capacity-is it a state or a trait?, triggers for assessment of decisional capacity, methods for enhancing capacity, and decisional capacity in people with substance use disorders. Finally, we discuss some relevant health policy recommendations.

Emerging empirical evidence on the ethics of schizophrenia research

Many challenging ethical questions come with the scientific efforts to understand the nature and treatment of schizophrenia. The empirical study of ethical aspects of schizophrenia research has sought to clarify and resolve many of these questions. In this article we provide an overview of the existing data-based literature on schizophrenia research ethics and outline directions for future inquiry. We examine 5 broad categories of inquiry into the ethics of schizophrenia research: (1) Scientific designs (eg, placebo-controlled studies and medication-free intervals, prodromal and high-risk research, and genetics research); (2) informed consent and decision-making capacity, including assessment of decisional abilities, as well as intervention studies; (3) understanding and perceptions of risk and benefit (including the therapeutic misconception); (4) influences on research participation (including voluntarism, altruism, and other motivations); and (5) key participant safeguards, such as protocol review and participant advocates. We discuss how empirical work in each of these areas answers certain questions and raises new ones. Finally, we highlight important gaps in our understanding of ethically relevant aspects of schizophrenia research and offer a specific research agenda for empirical ethics.