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O'Mahony C. The reform of Irish mental health law: Aligning with human rights obligations? INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2024; 95:102004. [PMID: 38943689 DOI: 10.1016/j.ijlp.2024.102004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/17/2024] [Accepted: 06/23/2024] [Indexed: 07/01/2024]
Abstract
This article critically examines the proposed reforms to Irish mental health law the Mental Health Act 2001 (2001 Act). The article will provide background to the 2001 Act and the lengthy law reform process, which has resulted in the publication of the Heads of Bill that propose significant amendments. The article assesses the suggested reforms, considering Ireland's 2018 ratification of the UN Convention on the Rights of Persons with Disabilities (CRPD), which provides important context to the law reform process. The 2001 Act is the primary piece of legislation regulating mental health services and safeguarding the rights of persons subject to the legislation in Ireland. While passed in 2001, the legislation did not come into effect until 2006. The 2001 Act was seen as bringing Irish mental health law into compliance with international human rights law, in particular the European Convention on Human Rights (ECHR). However, Ireland's ratification of the CRPD has necessitated closer scrutiny of the legislation. This review has culminated in the publication of a Heads of Bill in July 2021 and pre-legislative scrutiny by the responsible parliamentary committee in 2022. The long title of the Heads of Bill explicitly states its goal of safeguarding individual autonomy and underscores its commitment to upholding and advancing the rights of people subject to the legislation. The analysis of the Heads of Bill addresses several key areas. These areas include a background to the long process of review, new guiding principles, the category of persons under the mental health legislation, mental health tribunals, consent to treatment, advance healthcare directives, provisions relating to children and young people, and independent advocacy. Based on this analysis of the Heads of Bill, recommendations are suggested which would strengthen respect for the human rights of persons subject to the legislation.
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Affiliation(s)
- Charles O'Mahony
- School of Law, University of Galway, University Road, Galway H91 TK33, Ireland.
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Marcó-García S, Ariyo K, Owen GS, David AS. Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis. Psychol Med 2024; 54:1074-1083. [PMID: 38433596 DOI: 10.1017/s0033291724000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Decision-making capacity (DMC) among psychiatric inpatients is a pivotal clinical concern. A review by Okai et al. (2007) suggested that most psychiatric inpatients have DMC for treatment, and its assessment is reliable. Nevertheless, the high heterogeneity and mixed results from other studies mean there is considerable uncertainty around this topic. This study aimed to update Okai's research by conducting a systematic review with meta-analysis to address heterogeneity. We performed a systematic search across four databases, yielding 5351 results. We extracted data from 20 eligible studies on adult psychiatric inpatients, covering DMC assessments from 2006 to May 2022. A meta-analysis was conducted on 11 papers, and a quality assessment was performed. The study protocol was registered on PROSPERO (ID: CRD42022330074). The proportion of patients with DMC for treatment varied widely based on treatment setting, the specific decision and assessment methods. Reliable capacity assessment was feasible. The Mini-Mental State Examination (MMSE), Global Assessment of Function (GAF), and Brief Psychiatric Rating Scale (BPRS) predicted clinical judgments of capacity. Schizophrenia and bipolar mania were linked to the highest incapacity rates, while depression and anxiety symptoms were associated with better capacity and insight. Unemployment was the only sociodemographic factor correlated with incapacity. Assessing mental capacity is replicable, with most psychiatric inpatients able to make treatment decisions. However, this capacity varies with admission stage, formal status (involuntary or voluntary), and information provided. The severity of psychopathology is linked to mental capacity, though detailed psychopathological data are limited.
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Affiliation(s)
- Silvia Marcó-García
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain
- Etiopathogenesis and treatment of severe mental disorders (MERITT), Sant Joan de Déu Research Institute, Sant Joan de Déu Foundation, Barcelona, Spain
- Department of Social Psychology and Quantitative Psychology, Faculty of Psychology, University of Barcelona, 08035 Barcelona, Spain
| | - Kevin Ariyo
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Gareth S Owen
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony S David
- Division of Psychiatry, UCL Institute of Mental Health, University College London, London, UK
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Curley A, Watson C, Kelly BD. Capacity to consent to treatment in psychiatry inpatients - a systematic review. Int J Psychiatry Clin Pract 2022; 26:303-315. [PMID: 34941467 DOI: 10.1080/13651501.2021.2017461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Mental capacity for treatment decisions in psychiatry inpatients is an important ethical and legal concern, especially in light of changes in mental capacity legislation in many jurisdictions. AIMS To conduct a systematic review of literature examining the prevalence of mental capacity for treatment decisions among voluntary and involuntary psychiatry inpatients, and to assess any correlations between research tools used to measure mental capacity and binary judgements using criteria such as those in capacity legislation. METHOD We searched PsycINFO, Ovid MEDLINE and EMBASE for studies assessing mental capacity for treatment decisions in people admitted voluntarily and involuntarily to psychiatric hospitals. RESULTS Forty-five papers emanating from 33 studies were identified. There was huge variability in study methods and often selective populations, but the prevalence of decision-making capacity varied between 5% and 83.7%. These figures resulted from studies using cut-off scores or categorical criteria only. The prevalence of decision-making capacity among involuntary patients ranged from 7.7% to 42%, and among voluntary patients ranged from 29% to 97.9%. Two papers showed positive correlations between clinicians' judgement of decision-making capacity and scores on the MacArthur Competence Assessment Tool for Treatment; two papers showed no such correlation. CONCLUSIONS Not all voluntary psychiatry inpatients possess mental capacity and many involuntary patients do. This paradox needs to be clarified and resolved in mental health legislation; supported decision-making can help with this task.Key PointsLegislative changes for mental capacity are taking place in many jurisdictions.This is an important human rights issue for many people, including psychiatry inpatients.In our review, we found the prevalence of decision-making capacity varies between 5% and 83.7% in psychiatry inpatients.Not all voluntary inpatients have decision-making capacity.Many involuntary inpatients have mental capacity to make decisions.Supported decision-making can help those with impairments in their mental capacity.
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Affiliation(s)
- Aoife Curley
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Cavan Monaghan Mental Health Service, Monaghan, Ireland
| | - Carol Watson
- Cavan Monaghan Mental Health Service, Monaghan, Ireland
| | - Brendan D Kelly
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Tallaght, Dublin, Ireland
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Sugawara N, Yasui-Furukori N, Yamada S, Aoki M, Takeuchi Y, Miyazaki K, Shimoda K. Relationship Between Cognitive Functions and Decision-Making Capacity in Older Institutionalized Patients with Schizophrenia: A Preliminary Study. Neuropsychiatr Dis Treat 2022; 18:891-897. [PMID: 35450392 PMCID: PMC9017691 DOI: 10.2147/ndt.s357067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/06/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Decision-making capacity for patients with psychiatric disorders is an important and controversial issue in clinical care settings. The aim of this study was to (1) evaluate the level of decision-making capacity of older institutionalized patients suffering from schizophrenia and (2) determine whether their diminished capacity is associated with specific aspects of cognitive impairment. METHODS Using a cross-sectional design, we recruited 48 older institutionalized patients (mean age ± standard deviation: 60.0 ± 14.0 years) who were diagnosed with schizophrenia. Participants underwent the assessments by the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the Japanese version of the Brief Assessment of Cognition in Schizophrenia (Japanese-BACS). RESULTS The understanding summary scores of the MacCAT were found to have a significant positive correlation with the attention and verbal fluency subscale scores of the Japanese-BACS and negative correlations with age and duration of illness. In addition, the appreciation and reasoning summary scores had a significant negative correlation with age. In a linear regression model with a stepwise selection procedure, age, sex, and verbal fluency subscale scores were associated with understanding summary scores. CONCLUSION The generally poor cognitive performance of inpatients with chronic schizophrenia indicated that the informed consent process for their treatment might pressure these patients on the basis of cognitive demands. It is necessary for psychiatrists to assess individual decision-making capacity and to increase their patients' involvement in the treatment process.
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Affiliation(s)
- Norio Sugawara
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan.,Department of Clinical Epidemiology, Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan.,Department of Neuropsychiatry, Hirosaki University, School of Medicine, Aomori, Japan
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan.,Department of Neuropsychiatry, Hirosaki University, School of Medicine, Aomori, Japan
| | - Sonoko Yamada
- Department of Neuropsychiatry, Hirosaki University, School of Medicine, Aomori, Japan
| | - Mei Aoki
- Department of Neuropsychiatry, Hirosaki University, School of Medicine, Aomori, Japan
| | - Yoshitaka Takeuchi
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan.,Shiseikai, Takizawa Hospital, Tochigi, Japan
| | - Kensuke Miyazaki
- Department of Neuropsychiatry, Hirosaki-Aiseikai Hospital, Aomori, Japan
| | - Kazutaka Shimoda
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan
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Kotzé C, Roos JL, Ehlers R. End-of-Life Decision-Making Capacity in Older People With Serious Mental Illness. Front Psychiatry 2021; 12:752897. [PMID: 34630189 PMCID: PMC8492912 DOI: 10.3389/fpsyt.2021.752897] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The study's main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness. Methods: A cross-sectional, observational study, was done at Weskoppies Psychiatric Hospital, Gauteng Province, South Africa that included 100 adults older than 60 years of age and diagnosed with serious mental illness. The Mini-Cog and a semi-structured clinical assessment of end-of-life decision-making capacity was done before a standardized interview, Assessment of Capacity to Consent to Treatment, was administered. This standardized instrument uses a hypothetical vignette to assess decision-making capacity and explores healthcare-related values. Results: The Assessment of Capacity to Consent to Treatment scores correlated (p < 0.001) with the outcomes of the semi-structured decision-making capacity evaluation. Significant correlations with impaired decision-making capacity included: lower scores on the Mini-Cog (p < 0.001); a duration of serious mental illness of 30-39 years (p = 0025); having a diagnosis of schizophrenia spectrum disorders (p = 0.0007); and being admitted involuntarily (p < 0.0001). A main finding was that 65% of participants had decision-making capacity for end-of-life decisions, were able to express their values and engage in advance care discussions. Discussion and Conclusion: Healthcare providers have a duty to initiate advance care discussions, optimize decision-making capacity, and protect autonomous decision-making. Many older patients with serious mental illness can engage in end-of-life discussions and can make autonomous decisions about preferred end-of-life care. Chronological age or diagnostic categories should never be used as reasons for discrimination, and older people with serious mental illness should receive end-of-life care in keeping with their preferences and values.
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Affiliation(s)
- Carla Kotzé
- Department of Psychiatry, Faculty of Health Sciences, School of Medicine, Weskoppies Psychiatric Hospital, University of Pretoria, Pretoria, South Africa
| | - Johannes Lodewikus Roos
- Department of Psychiatry, Faculty of Health Sciences, School of Medicine, Weskoppies Psychiatric Hospital, University of Pretoria, Pretoria, South Africa
| | - René Ehlers
- Department of Statistics, Faculty of Natural and Agricultural Sciences, University of Pretoria, Pretoria, South Africa
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Stewart C, Biegler P, Brunero S, Lamont S, Tomossy GF. Mental Capacity Assessments for COVID-19 Patients: Emergency Admissions and the CARD Approach. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:803-808. [PMID: 33169263 PMCID: PMC7651828 DOI: 10.1007/s11673-020-10055-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/23/2020] [Indexed: 06/11/2023]
Abstract
The doctrine of consent (or informed consent, as it is called in North America) is built upon presumptions of mental capacity. Those presumptions must be tested according to legal rules that may be difficult to apply to COVID-19 patients during emergency presentations. We examine the principles of mental capacity and make recommendations on how to assess the capacity of COVID-19 patients to consent to emergency medical treatment. We term this the CARD approach (Comprehend, Appreciate, Reason, and Decide).
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Affiliation(s)
- Cameron Stewart
- Sydney Law School, University of Sydney, NSW, 2006, Australia.
| | - Paul Biegler
- Monash Bioethics Centre, Monash University, Clayton, VIC, 3800, Australia
| | - Scott Brunero
- School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, 2751, Australia
- School of Health and Human Sciences, Southern Cross University, Lismore, NSW, 2480, Australia
- Mental Health Liaison Nursing, Prince of Wales Hospital, Randwick, NSW, 2034, Australia
| | - Scott Lamont
- School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, 2751, Australia
- School of Health and Human Sciences, Southern Cross University, Lismore, NSW, 2480, Australia
- Mental Health Liaison Nursing, Prince of Wales Hospital, Randwick, NSW, 2034, Australia
| | - George F Tomossy
- Macquarie Law School, Macquarie University, NSW, 2154, Australia
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Pons EV, Salvador‐Carulla L, Calcedo‐Barba A, Paz S, Messer T, Paccardi B, Zeller SL. The capacity of schizophrenia and bipolar disorder individuals to make autonomous decisions about pharmacological treatments for their illness in real life: A scoping review. Health Sci Rep 2020; 3:e179. [PMID: 32782974 PMCID: PMC7415958 DOI: 10.1002/hsr2.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND AIM Having decision making capacity is central to the exercise of autonomy in mental health care. The objective of this scoping review is to summarize the evidence on the capacity of people with schizophrenia or bipolar disorder to make decisions about their treatment in real life to support medical practice. METHODS Systematic search of observational studies on the assessment of capacity of patients with schizophrenia, psychosis, or bipolar disorder to make healthcare and treatment-related decisions, conducted in any clinical setting published up to January 31, 2020 was performed. Free text searches and medical subject headings in English were combined in PubMed, Scopus, CINAHL, and PsycInfo. Publications were selected as per inclusion and exclusion criteria. The Newcastle-Ottawa Scale for observational studies was used to assess the quality of publications. RESULTS Thirty publications were reviewed. According to the Newcastle-Ottawa Scale criteria, the publications reviewed were good quality. Findings showed that more than 70% of schizophrenia and schizoaffective disorder outpatients understood treatment options at the point of making decisions about their illness and healthcare. Patients treated voluntarily had considerably better scores for decisional capacity than those treated involuntarily. The burden of psychiatric symptoms could compromise decisional capacity temporarily. Decision-making capacity improved over time from admission to discharge from hospital, and with treatment among psychiatry inpatients. Schizophrenia and bipolar disorder patients could be as competent as nonpsychiatric individuals in making decisions about their treatments in everyday life. CONCLUSIONS This scoping review provides a body of evidence for healthcare professionals in need of assessing the capacity of schizophrenia and bipolar disorder patients for autonomously decide about their treatments. Decisional capacity judgements should consider variations in capacity over time and be based on the type of decision to be made, the severity of symptoms, and the specific phase of the mental disorder.
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Affiliation(s)
- Enric Vincens Pons
- Department of PsychiatryParc Sanitari Sant Joan de Déu, Sant Boi de LlobregatBarcelonaSpain
| | - Luis Salvador‐Carulla
- Centre for Mental Health ResearchResearch School of Population Health, College of Health and Medicine, Australian National UniversityCanberraAustralia
| | - Alfredo Calcedo‐Barba
- Department of Psychiatry, Hospital Gregorio MarañónMedical School at the Universidad Complutense de MadridMadridSpain
| | | | - Thomas Messer
- Department of PsychiatryDanuviusklinikPfaffenhofenGermany
| | - Bruno Paccardi
- Psychiatric UnitSanta Chiara University Hospital, University of PisaPisaItaly
| | - Scott L. Zeller
- Department of PsychiatryUniversity of CaliforniaCaliforniaUSA
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Irish Medical Organisation Doolin Memorial Lecture 2019: rhetoric and reality in mental health—Ireland and the world. Ir J Med Sci 2020; 189:1127-1134. [DOI: 10.1007/s11845-019-02163-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
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Abstract
Capacity legislation in Ireland is evolving. The Assisted Decision-Making (Capacity) Act 2015 has been passed into law, but its main provisions are yet to be commenced. This paper compares the law and its practical implications currently and under the new legislation. Quick reference algorithms for frontline clinicians are proposed.
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Curley A, Murphy R, Fleming S, Kelly BD. Age, psychiatry admission status and linear mental capacity for treatment decisions. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 66:101469. [PMID: 31706384 DOI: 10.1016/j.ijlp.2019.101469] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/02/2019] [Indexed: 06/10/2023]
Abstract
The relationship between age and mental capacity among psychiatry inpatients is not fully understood. We aimed to assess mental capacity for treatment decisions in voluntary and involuntary psychiatry inpatients in Ireland and, in this analysis of our data-set, to elucidate the linear relationship, if any, between linear (as opposed to categorical) mental capacity and age. We used the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to assess mental capacity for treatment decisions in 215 psychiatry inpatients (176 voluntary and 39 involuntary) in four psychiatry admission units in Ireland. Mean age was 46.2 years and majorities were male (58.1%), never married (74.0%), unemployed (64.2%) and of Irish ethnicity (87.0%). The most common primary diagnoses were schizophrenia and related disorders (42.8%) followed by affective disorders (36.7%). On multi-variable linear regression analysis, linear mental capacity was significantly associated with voluntary admission status, being employed, having a primary diagnosis other than schizophrenia or a related disorder, and younger age. Together, these factors accounted for 44.4% of the variance in mental capacity between participants. Overall, while increased age is associated with diminished mental capacity, other factors appear more significant, including involuntary admission status which is likely an indicator of symptom severity. There is a need for further research to (a) elucidate the relationships between the significant factors identified in this study and the cognitive status of patients (which impacts on assessments of mental capacity); (b) identify and elucidate other factors of likely relevance to mental capacity (e.g. medical illness, medication use); and (c) translate these findings into targeted interventions to support decision-making in clinical practice among psychiatry inpatients, especially those with involuntary status.
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Affiliation(s)
- Aoife Curley
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin D24 NR0A, Ireland.
| | - Ruth Murphy
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin D24 NR0A, Ireland.
| | - Sean Fleming
- Department of Medicine, Midland Regional Hospital, Dublin Road, Portlaoise, County Laois R32 RW61, Ireland.
| | - Brendan D Kelly
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin D24 NR0A, Ireland.
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