Impact of decisional capacity on the use of leverage to encourage treatment adherence

Capacity to Consent in Healthcare: A Systematic Review and Meta-Analysis Comparing Patients with Bipolar Disorders and Schizophrenia Spectrum Disorders

Background: Mental capacity is a fundamental aspect that enables patients to fully participate in various healthcare procedures. To assist healthcare professionals (HCPs) in assessing patients' capacity, especially in the mental health field, several standardized tools have been developed. These tools include the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), and the Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD). The core dimensions explored by these tools include Understanding, Appreciation, Reasoning, and Expression of a choice. Objective: This meta-analysis aimed to investigate potential differences in decision-making capacity within the healthcare context among groups of patients with bipolar disorders (BD) and schizophrenia spectrum disorders (SSD). Methods: A systematic search was conducted on Medline/Pubmed, and Scopus. Additionally, Google Scholar was manually inspected, and a manual search of emerging reviews and reference lists of the retrieved papers was performed. Eligible studies were specifically cross-sectional, utilizing standardized assessment tools, and involving patients diagnosed with BD and SSD. Data from the studies were independently extracted and pooled using random-effect models. Hedges' g was used as a measure for outcomes. Results: Six studies were identified, with three studies using the MacCAT-CR, two studies the MacCAT-T, and one the CAT-PAD. The participants included 189 individuals with BD and 324 individuals with SSD. The meta-analysis revealed that patients with BD performed slightly better compared to patients with SSD, with the difference being statistically significant in the domain of Appreciation (ES = 0.23, 95% CI: 0.01 to 0.04, p = 0.037). There was no statistically significant difference between the two groups for Understanding (ES = 0.09, 95% CI:-0.10 to 0.27, p = 0.352), Reasoning (ES = 0.18, 95% CI: -0.12 to 0.47, p = 0.074), and Expression of a choice (ES = 0.23, 95% CI: -0.01 to 0.48, p = 0.60). In the sensitivity analysis, furthermore, when considering only studies involving patients in symptomatic remission, the difference for Appreciation also resulted in non-significant (ES = 0.21, 95% CI: -0.04 to 0.46, p = 0.102). Conclusions: These findings indicate that there are no significant differences between patients with BD and SSD during remission phases, while differences are minimal during acute phases. The usefulness of standardized assessment of capacity at any stage of the illness should be considered, both for diagnostic-therapeutic phases and for research and advance directives. Further studies are necessary to understand the reasons for the overlap in capacity between the two diagnostic categories compared in this study.

The assessment of decision-making competence in patients with depression using the MacArthur competence assessment tools: A systematic review

PURPOSE

This is a systematic review of the usefulness of the MacArthur Competence Assessment Tools (MacCAT) in assessing the decision-making competence in patients with depression.

DESIGN AND METHODS

A systematic literature search was performed.

FINDINGS

Eleven studies met the search criteria. The decision-making capacity was impaired in 9-31% of the patients with depression. There was inconsistency regarding the differences of MacCAT scores between patients with depression and controls, while relatively large effect sizes were found on the Appreciation and Reasoning MacCAT subscales.

PRACTICE IMPLICATIONS

The MacCAT appears to be a useful tool for measuring decision-making capacity in patients with depression, but the association between depression and competence is not consistent. The mechanisms mediating such association are likely to be complex and multifactorial.

Behavioral and Psychological Symptoms Impact Clinical Competence in Alzheimer's Disease

Decision-making is considered a fundamental aspect of personal autonomy and can be affected in psychiatric and neurologic diseases. It has been shown that cognitive deficits in dementia impact negatively on decision-making. Moreover, studies highlighted impaired clinical competence in neuropsychiatric disorders, such as schizophrenia and bipolar disorder. In this context, the current study explored the relationship between behavioral and psychological symptoms of dementia (BPSD) and clinical competence, especially the capacity to consent to treatment, in Alzheimer's disease (AD). Seventy-one patients with mild to moderate AD participated, completing assessments for capacity to consent to treatment, general cognition and neuropsychiatric disturbances. For each neuropsychiatric symptom, patients with and without the particular disturbance were compared on the different subscales of the MacArthur Competence Tool for Treatment (MacCAT-T; Understanding, Appreciation, Reasoning and Expression). The results showed that patients presenting delusions, as well as apathetic patients, had a lower ability to express a clear treatment choice compared to patients without these symptoms. By contrast, patients with dysphoria/depression had higher scores on this variable. Additionally, AD patients with euphoria had more difficulties discussing consequences of treatment alternatives compared to patients without this disturbance. None of the differences were confounded by global cognition. There were no between-group differences in clinical decision-making for patients with hallucinations, agitation/aggression, anxiety, irritability, disinhibition and aberrant motor behavior. These findings highlight the importance of taking BPSD into account when assessing decision-making capacity, especially clinical competence, in AD. Furthermore, reducing BPSD may lead to better clinical competence in patients with AD, as well as to improvements in patients and caregivers' quality of life.

What Patients With Severe Mental Illness Transitioning From Hospital to Community Have to Say About Care and Shared Decision-Making

Shared decision-making (SDM) has been slow to disseminate in mental health. We conducted focus groups with ten individuals with serious mental illness (SMI) treated in a 90 day, outpatient transitional care clinic. Parallel groups were held with family caregivers (n = 8). Individuals with SMI wanted longer visits, to have their stories heard, more information about options presented simply, to hear from peers about similar experiences, and a bigger say in treatment choices. Caregivers wanted to be invited to participate to a larger extent.  Results suggest that after a decade, SDM may not have the expected penetration in community mental health.

Psychiatric Providers' Willingness to Participate in Shared Decision Making When Prescribing Psychotropics

Background: Patients with mental health disorders experience difficulty in selecting treatments. With a paternalistic approach, patients are not offered an opportunity to provide input. Shared decision making (SDM) occurs when providers and patients collaborate on informed treatment decisions. Research on psychiatric providers' perceptions toward SDM is limited. Objective: This pilot study aimed to determine psychiatric providers' willingness to engage in SDM and factors that influence willingness. Methods: This cross-sectional, self-report study measured willingness, attitude, experiences, and barriers related to SDM as well as demographic/practice characteristics. A survey was e-mailed to psychiatric providers at 3 psychiatric institutions. Results: Out of 80 providers e-mailed, 29 (36.3%) responded. Providers had a favorable attitude toward SDM (3.26 ± 0.24, range = 1-4) and a high willingness to use SDM (3.43 ± 0.50, range = 1-4). The most common SDM methods were discussions (96.6%) and written material (89.7%). Common perceived barriers included limited patient capacity (86.2%) and limited time with patient (62.1%). Current SDM users (3.46 ± 0.51) had a higher willingness to engage in SDM than noncurrent users (3.00 ± 0.00), t = 4.63, df = 25.0, P < .001. Attitude and willingness were positively related (r = .62, P < .001). Attitude did not vary based on demographic/practice characteristics. Conclusions: Willingness to use SDM was positively related to a favorable attitude toward SDM. Larger, geographically diverse, randomized controlled trials need to be conducted to evaluate the willingness of psychiatric providers to conduct SDM.

Mental capacity and consent to treatment in psychiatric patients: the state of the research

PURPOSE OF REVIEW

The past three decades have seen the emergence of the field of decision-making capacity research. The growth has been such that there are several reviews covering a variety of subtopics within the field. The goal is to briefly summarize the state of research.

RECENT FINDINGS

Most studies in this field use the MacArthur Competence Assessment Tools for the decisional capacity assessment. Studies in psychiatric patients indicate incapacity is common (20-30%), but the majority are capable of making treatment decisions. Positive symptoms (hallucinations, delusions); negative symptoms (unusual thought content, conceptual disorganization); severity of symptoms; involuntary admission; lack of insight and treatment refusal were the stronger predictors for incapacity in acute and cognitive dysfunction in chronic patients.

SUMMARY

Mental capacity has complex relationships with psychopathological variables, and these relationships are different according to diagnostic group. More research is needed to determine the clinical parameters related to the lack of capacity to make treatment decisions in psychiatric patients.

Enhancement of outpatient treatment adherence: Patients' perceptions of coercion, fairness and effectiveness

Interventions aimed at enhancing psychiatric patients' outpatient treatment adherence frequently include informal coercion such as inducements, and threats of negative sanctions. Little is known about patients' subjective perspective concerning these practices. This study examined the perceived coercion, and also the appraisal of the fairness and effectiveness of the treatment. A total of 187 psychiatric patients with different diagnoses were interviewed using a structured questionnaire that included socio-demographic and clinical data, insight into illness (ITAQ), psychopathology (BPRS), functioning (GAF) and a modified version of the MacArthur Admission Experience Survey (AES) as a measure of perceived coercion, fairness and effectiveness. Bivariate correlations and logistic regression analyses were used to identify the influencing factors on the outcome variables. Perceived coercion was associated with experience with informal coercive treatment pressures (OR 2.5-2.9; P<0.05), and a main diagnosis of a schizophrenic disorder (OR 3.8; P<0.001). Experience with informal coercion was inversely associated with fairness (OR 0.3-0.4; P<0.05), but not with effectiveness. Patients with more insight into their illness indicated higher fairness and effectiveness concerning the procedures for enhancing their treatment adherence (OR 3.1; P<0.01). Insight into illness was not associated with perceived coercion. This might indicate that enhancing insight using psycho-educational approaches and high transparency when applying informal coercive practices could improve patients' appreciation for these procedures. They could probably cope better with perceived coercion when understanding its purpose, and when they perceive they are being treated fairly.

Shared decision-making in the primary care treatment of late-life major depression: a needed new intervention?

OBJECTIVE

We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions.

METHODS

We explore the characteristics and techniques of patient-clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults.

RESULTS

We describe a SDM intervention to engage older adults in depression treatment in the primary care sector.

CONCLUSIONS

It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes.

What would Mary Douglas do? A commentary on Kahan et al., "Cultural cognition and public policy: the case of outpatient commitment laws"

Involuntary outpatient commitment is a highly controversial issue in mental health law. Strong supporters of outpatient commitment see it as a form of access to community-based mental health care and a less restrictive alternative to hospitalization for people with severe mental illness; vocal opponents see it as an instrument of social control and an unwarranted deprivation of individual liberty. Kahan and colleagues apply the theory of "cultural cognition" in an empirical study of how cultural worldviews influence support for outpatient commitment laws among the general public and shape perceptions of evidence for these laws' effectiveness. This article critiques Kahan et al. and offers an alternative perspective on the controversy, emphasizing particular social facts underlying stakeholders' positions on outpatient commitment laws.

[Psychiatric advance directives and the role of autonomy]

Although psychiatric advance directives (PADs) are grounded in the ethics of autonomy, the relationship between the two is unclear. PADs are legal documents that allow individuals with mental illness to record their treatment preferences should they become incompetent in the future. The relationship between autonomy and PADs has been discussed in ethical, legal, and philosophical terms, but has not been clearly operationalized for clinical purposes. Autonomy is a fundamental ethical value that includes having the independence from outside controlling influences and the mental capacity to direct one's personal actions. Individuals with mental illness sometimes require assistance to understand their ethical and legal rights with respect to autonomous choice, and professional stakeholders need education regarding the importance of autonomy for clinical practice. Competency to consent to treatment is the mental prerequisite that ensures individuals with mental illness are able to complete PADs with insight, whereas autonomy is the value that empowers individuals to work towards their recovery.

Recent advances in shared decision making for mental health

PURPOSE OF REVIEW

Shared decision making (SDM) in nonmental health populations has documented positive services and health benefits. To advance integration of SDM into mental healthcare, researchers have outlined several priorities for future research. These include (1) clarifying the role of SDM in mental healthcare; (2) understanding patient and provider perspectives on SDM; (3) assessment of SDM practice in mental health settings; and (4) outcomes of SDM in mental health populations. This article will review recent advances in these areas.

RECENT FINDINGS

The current literature shows that SDM can play a role in the mental health treatment process from entry into care to recovery. Patients and providers find SDM acceptable and express a willingness to engage in SDM for reasons that are multifactorial. Barriers to SDM exist in mental health decision making including patient preferences and provider-level biases. Lastly, outcome research provides encouraging preliminary evidence for feasibility and effectiveness of SDM during the mental health encounter.

SUMMARY

Although there have not been a great number of SDM studies in mental health to date, the positive effects of SDM are comparable to those documented in general nonmental health patient groups, suggesting that future research has the potential to result in findings that are likely to be helpful for patients with psychiatric disorders.

Mental capacity in psychiatric patients: Systematic review

BACKGROUND

Mental capacity is central to legal and ethical debates on the use of compulsion in psychiatry.

AIMS

To describe the clinical epidemiology of mental incapacity in patients with psychiatric disorders, including interrater reliability of assessments, frequency in the psychiatric population and associations of mental incapacity.

METHOD

Cross-sectional studies of capacity to consent to treatment for psychiatric patients were systematically reviewed from Medline, EMBASE and PsycInfo databases. Information on the reliability of assessments, frequency and associations of mental incapacity was extracted.

RESULTS

Out of 37 papers reviewed, 29 different capacity assessment tools were identified. Studies were highly heterogeneous in their measurement and definitions of capacity. Interrater reliabilities between tools were high. Studies indicate incapacity is common (median 29%) but the majority of psychiatric in-patients are capable of making treatment decisions. Psychosis, severity of symptoms, involuntary admission and treatment refusal were the strongest risk factors for incapacity.

CONCLUSIONS

Mental capacity can be reliably assessed. The majority of psychiatric in-patients have capacity, and socio-demographic variables do not have a major impact but clinical ones do.

Promoting the value and practice of shared decision-making in mental health care

Active consumer participation is critical in contemporary mental health care and treatment planning and has been a staple of the field of psychiatric rehabilitation for the last three decades. Providing the opportunity for consumers to chose interventions that fit personal preferences and recovery increase the likelihood that these interventions will enhance personal meaning, satisfaction and quality of life (Improving the Quality of Health Care for Mental and Substance Use Conditions, 2006). Similarly, self-determination and shared decision-making are critical components of recovery. As stated in the President's New Freedom Commission on Mental Health Final Report, recovery from mental illnesses should be the expectation in mental health care with services and treatments that are consumer and family-driven. Mental health care should be planned and delivered to ensure that consumers and families with children with mental health problems receive real and meaningful choices about treatment options and providers. The purpose of this paper is to explore the value and use of shared decision-making in health and mental health care, briefly examine the advantages and disadvantages of shared decision making and propose next steps in advancing use of shared decision-making in mental health care.

PLC or TLC: is outpatient commitment the/an answer?

The lively debate over mandated community treatment in general and outpatient commitment laws (OPC) in particular has raised many issues. At its core, the debate is over how and to what extent laws should be formulated to persuade, leverage or coerce (PLC) persons with severe mental illness living in the community to comply with medications that mental health professionals believe they need. The alternative to PLC is what we call TLC (tender loving care): a strategy of using benefits - improved patient-centered treatment, entitlements and service delivery, including assertive outreach - rather than penalties or conditions on access to services, to induce compliance. We examine three aspects of the debate: (1) the empirical case for the need for OPC court orders to maintain revolving-door severely mentally ill persons in the community; (2) the normative argument over whether such orders constitute coercion, and, if so, whether that coercion is justifiable; and (3) the incentives such orders create to leverage community providers to augment resources and tailor treatment and services to entice patients to become willing participants in the management of their disorders.