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

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.

Consent for Research Involving Spanish- and English-Speaking Latinx Adults With Schizophrenia

BACKGROUND

Latinxs are vastly underrepresented in mental health research; one of many contributing factors may be complexities in the research consent process, including language preferences. We examined determinants of comprehension of research consent procedures and tested the effects of a preconsent research schema condition among 180 adults with schizophrenia (60 Latinx-English and 60 Latinx-Spanish preference, and 60 non-Latinx White).

STUDY DESIGN

Participants were randomly assigned (equal allocation) to an educational session regarding clinical research concepts and processes (schema condition) or to an attention control. Following a subsequent simulated consent procedure for a hypothetical drug trail, comprehension of consent disclosures was measured with 2 standard measures.

STUDY RESULTS

One-way ANOVAs showed significant medium effect size differences between ethnicity/language groups on both measures of comprehension (η2s = 0.066-0.070). The Latinx-Spanish group showed lower comprehension than non-Latinx White participants; differences between the 2 Latinx groups did not reach statistical significance. Group differences were not statistically significant after adjusting for differences in education, or on scores from structured measures of acculturation, health literacy, or research literacy. Two-way ANOVAs showed no significant main effects for consent procedure on either comprehension measure (Ps > .369; partial η2s < 0.006) and no significant group-by-consent interactions (Ps > .554; partial η2s < 0.008).

CONCLUSIONS

Although the preconsent procedure was not effective, the results suggest health and research literacy may be targets for reducing disparities in consent comprehension. The onus is on researchers to improve communication of consent information as an important step to addressing health care disparities.

Do Suicide Attempters Have a Right Not to Be Stabilized in an Emergency?

The standard of care in the United States favors stabilizing any adult who arrives in an emergency department after a failed suicide attempt, even if he appears decisionally capacitated and refuses life-sustaining treatment. I challenge this ubiquitous practice. Emergency clinicians generally have a moral obligation to err on the side of stabilizing even suicide attempters who refuse such interventions. This obligation reflects the fact that it is typically infeasible to determine these patients' level of decisional capacitation-among other relevant information-in this unique setting. Nevertheless, I argue, stabilizing suicide attempters over their objection sometimes violates a basic yet insufficiently appreciated right of theirs-the right against bodily invasion. In such cases, it is at least prima facie wrong to stabilize a patient who wants to die even if they lack a contrary advance directive or medical order and suffer from no terminal physical illness.

Schizophrenia and Emergency Medicine

Schizophrenia is a chronic condition characterized by positive symptoms (auditory hallucinations, delusion), negative symptoms (avolition, social withdrawal), and disorganized thoughts/behaviors. Although the pathophysiology is incompletely understood, several neurobiological mechanisms have been proposed. Treatment usually involves antipsychotic medication as well as psychotherapy and supportive services. When evaluating patients in the emergency department, acute safety considerations are paramount. Patients should be assessed for suicide risk, violence risk, inability to care for self, and the risk of being the victim of a crime. Persons with schizophrenia are at an increased risk of substance use and a variety of medical problems.

Shared decision making and associated factors among patients with psychotic disorders: a cross-sectional study

BACKGROUND

Shared decision making is a process where patients and clinicians collaborate to make treatment choices based on the patients' preferences and best available evidence. The implementation of shared decision making remains limited for patients with psychotic disorders despite being recommended at policy level, being advocated as ethical right and wanted by the patient's. A barrier to implementation that is often mentioned is reduced decision-making capacity among patients. The challenges of implementing shared decision making highlights a need for more knowledge on shared decision making for these patients. Moreover, the association between patient-related characteristics and shared decision making is unclear, and further research have been suggested. More knowledge of factors associated with involvement in shared decision making can enhance understanding and help to empower patients in the decision-making process. The current study examined the extent of reported shared decision making among patients with a psychotic disorder in mental health care and factors associated with shared decision making.

METHODS

This study included 305 participants with a psychotic disorder from 39 clinical inpatient and outpatient sites across Norway. Shared decision making was assessed using the CollaboRATE survey. A linear mixed model was estimated to assess characteristics associated with shared decision making scores.

RESULTS

The CollaboRATE mean score was 6.3 (ranging from 0 to 9), the top score was 14.1% and increased global satisfaction with services was significantly associated with a higher level of shared decision making (regression coefficient 0.27, 95% confidence interval (0.23; 0.32), p < 0.001).

CONCLUSIONS

The low top score shows that few patients felt that they received the highest possible quality of shared decision making, indicating that many patients found room for improvement. This suggests that services for patients with psychotic disorders should be designed to give them a greater role in decision making. Shared decision making might play a key role in mental health care, ensuring that patients with psychotic disorders are satisfied with the services provided.

TRIAL REGISTRATION

NCT03271242, date of registration: 5 Sept. 2017.

Informed consent practices in clinical research: present and future

Clinical research must balance the need for ambitious recruitment with protecting participants' autonomy; a requirement of which is informed consent. Despite efforts to improve the informed consent process, participants are seldom provided sufficient information regarding research, hindering their ability to make informed decisions. These issues are particularly pervasive among patients experiencing acute illness or neurological impairment, both of which may impede their capacity to provide consent. There is a critical need to understand the components, requirements, and methods of obtaining true informed consent to achieve the vast numbers required for meaningful research. This paper provides a comprehensive review of the tenets underlying informed consent in research, including the assessment of capacity to consent, considerations for patients unable to consent, when to seek consent from substitute decision-makers, and consent under special circumstances. Various methods for obtaining informed consent are addressed, along with strategies for balancing recruitment and consent.

Consent, decisional capacity and guardianship in mental health research

Background: Research with adults who cannot give informed consent has important social value. However, enrolling adults who cannot consent in research raises significant ethical concerns.  Methods: To evaluate how researchers in low and middle-income countries (LMICs) can assess individuals' decisional capacity, and the conditions under which it is appropriate, and the conditions under which it is not appropriate to include individuals who lack decisional capacity.  Results: In LMICs, where resources may be limited, implementing protections for adults with decisional incapacity can be especially challenging. Recognition of the ethical concerns, and awareness of the circumstances and available resources, offers the means to protect these vulnerable participants. Conclusions: Researchers in low and middle-income countries should be aware of steps they can take to ensure appropriate protections for subjects with decisional impairments while conducting clinical trials on methods to improve their clinical care.

Capacity to Consent for Treatment in Patients with Psychotic Disorder: A Cross-Sectional Study from North Karnataka

BACKGROUND

Recently, the Mental Healthcare Act (MHCA) 2017 was introduced in India. Being a right-based act, it has made the assessment of the capacity to consent an integral part of clinical work. To the best of our knowledge, there are no Indian studies on this topic. Hence, this study aimed to assess the capacity to consent to mental healthcare and treatment in patients with functional psychosis and the factors affecting the same.

METHODS

This cross-sectional study included participants with the ICD-10 DCR diagnosis of a psychotic disorder admitted in the psychiatry ward of a tertiary health care center in Karnataka, India. MacArthur Competence Assessment Tool for Treatment was used to assess the capacity to consent to treatment. Brief Psychiatric Rating Scale (BPRS) and the Beck Cognitive Insight Scale were applied to assess the severity of psychosis and level of insight, respectively.

RESULTS

A hundred participants were recruited. Twenty-four were found to have an intact capacity to consent to treatment. High BPRS scores (P value = 0.0002) and low insight scores (P value = 0.0002) were associated with an impaired capacity.

CONCLUSION

About one-fourth of participants had an intact capacity to consent to treatment. Higher severity of psychosis and a poorer insight into the illness were associated with impaired capacity to consent.

Consent, decisional capacity and guardianship in mental health research

Background: Research with adults who cannot give informed consent has important social value. However, enrolling adults who cannot consent in research raises significant ethical concerns.  Methods: To evaluate how researchers in low and middle-income countries (LMICs) can assess individuals’ decisional capacity, and the conditions under which it is appropriate to include and the conditions under which it is appropriate to exclude individuals who lack decisional capacity.  Results: In LMICs, where resources may be limited, implementing protections for adults with decisional incapacity can be especially challenging. Recognition of the ethical concerns, and awareness of the circumstances and available resources, offers the means to protect these vulnerable participants. Conclusions: Researchers in low and middle-income countries should be aware of steps they can take to ensure appropriate protections for subjects with decisional impairments while conducting clinical trials on methods to improve their clinical care.

Experiences of shared decision making among patients with psychotic disorders in Norway: a qualitative study

BACKGROUND

Shared decision making (SDM) is a process where the patient and the health professional collaborate to make decisions based on both the patient's preferences and the best available evidence. Patients with psychotic disorders are less involved in making decisions than they would like. More knowledge of these patients' experiences of SDM may improve implementation. The study aim was to describe and explore experiences of SDM among patients with psychotic disorders in mental health care.

METHODS

Individual interviews were conducted with ten persons with a psychotic disorder. They were service users of two community mental health centres. The transcribed material was analysed using qualitative content analysis.

RESULTS

Four-fifths of the participants in this study found that they received insufficient information about their health situation and treatment options. All participants experienced that only one kind of treatment was often presented, which was usually medication. Although the study found that different degrees of involvement were practised, two thirds of the participants had little impact on choices to be made. This was despite the fact that they wanted to participate and felt capable of participating, even during periods of more severe illness. The participants described how important it was that SDM in psychosis was based on a trusting relationship, but stated that it took time to establish such a relationship.

CONCLUSIONS

This study with ten participants indicates that patients with psychotic disorders experienced that they were not allowed to participate as much as they wanted to and believed they were capable of. Some patients were involved, but to a lesser degree than in SDM. More and better tailored information communicated within a trusting relationship is needed to provide psychotic patients with a better basis for active involvement in decisions about their health care.

Relationship Between Cognitive Functions and Decision-Making Capacity in Older Institutionalized Patients with Schizophrenia: A Preliminary Study

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.

COVID-19 Vaccine Uptake, Acceptance, and Hesitancy Among Persons With Mental Disorders During the Second Stage of China's Nationwide Vaccine Rollout

Persons with mental disorders (PwMDs) are a priority group for COVID-19 vaccination, but empirical data on PwMDs' vaccine uptake and attitudes toward COVID-19 vaccines are lacking. This study examined the uptake, acceptance, and hesitancy associated with COVID-19 vaccines among Chinese PwMDs during China's nationwide vaccine rollout. In total, 906 adult PwMDs were consecutively recruited from a large psychiatric hospital in Wuhan, China, and administered a self-report questionnaire, which comprised standardized questions regarding sociodemographics, COVID-19 vaccination status, attitudes toward COVID-19 vaccines, and psychopathology. Vaccine-recipients were additionally asked to report adverse events that occurred following vaccination. PwMDs had a much lower rate of vaccination than Wuhan residents (10.8 vs. 40.0%). The rates of vaccine acceptance and hesitancy were 58.1 and 31.1%, respectively. Factors associated with vaccine uptake included having other mental disorders [odds ratio (OR) = 3.63], believing that ≥50% of vaccine-recipients would be immune to COVID-19 (OR = 3.27), being not worried about the side effects (OR = 2.59), and being an outpatient (OR = 2.24). Factors associated with vaccine acceptance included perceiving a good preventive effect of vaccines (OR = 12.92), believing that vaccines are safe (OR = 4.08), believing that ≥50% of vaccine-recipients would be immune to COVID-19 (OR = 2.20), and good insight into the mental illness (OR = 1.71). Adverse events occurred in 21.4% of vaccine-recipients and exacerbated pre-existing psychiatric symptoms in 2.0% of vaccine-recipients. Nevertheless, 95.2% of vaccine-recipients rated adverse events as acceptable. Compared to the 58.1% vaccine acceptance rate and the 40.0% vaccination rate in the general population, the 10.8% vaccine coverage rate suggested a large unmet need for COVID-19 vaccination in Chinese PwMDs. Strategies to increase vaccination coverage among PwMDs may include provision of reliable sources of information on vaccines, health education to foster positive attitudes toward vaccines, a practical guideline to facilitate clinical decision-making for vaccination, and the involvement of psychiatrists in vaccine consultation and post-vaccination follow-up services.

Applying Genetic and Genomic Tools to Psychiatric Disorders: A Scoping Review

Introduction

The bioethics literature reflects significant interest in and concern with the use of genetic and genomic information in various settings. Because psychiatric treatment and research raises unique ethical, legal, and social issues, we conducted a scoping review of the biomedical, bioethics, and psychology literature regarding the application of genetic and genomic tools to psychiatric disorders (as listed in the DSM-5) and two associated behaviors or symptoms to provide a more detailed overview of the state of the field.

Objectives

The primary objective was to examine the available bioethics, biomedical, and psychology literature on applying genetic and genomic tools to psychiatric disorders (other than neurodevelopmental disorders) and two behaviors or symptoms sometimes associated with them (aggression or violence and suicidality) to identify the disorders to which these tools have been applied, the contexts in or purposes for which they have been applied, the ethical, legal, or social concerns associated with those uses, and proposed recommendations for mitigating those concerns.

Methods

We used Arksey and O’Malley’s scoping review framework: (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; and (5) collate, summarize, and report results (2005). We relied on Levac et al. to inform our application of the framework (2010). The PRISMA extension for scoping reviews checklist informed our reporting (2018). We searched three electronic databases MEDLINE (PubMed), Embase, and PsycInfo (EbscoHost) for peer-reviewed journal articles in English to identify relevant literature. One author screened the initial results and additional screening was done in consultation with other authors. A data extraction form using DSM-5 diagnostic categories (excluding neurodevelopmental disorders) was developed and two authors independently each reviewed approximately half of the articles. Inter-rater reliability was ensured by double-coding approximately 10% of the papers. An additional author independently coded 10% of the articles to audit the data.

Results

In 365 coded publications, we identified 15 DSM-5 diagnostic categories in addition to the two pre-selected behaviors or symptoms (aggression or violence and suicidality) to which genetic or genomic tools have been applied. We identified 11 settings in or purposes for which these tools were applied. Twenty-two types of ethical, legal, or social concerns associated with the application of genetic or genomic tools to these disorders or behaviors/symptoms were identified along with 13 practices or policies that could mitigate these concerns.

Conclusion

Genetic and genomic tools have been applied to a wide range of psychiatric disorders. These raise a range of ethical, legal, and social concerns. Additional research is warranted to better understand the concerns and effective ways to address them. Advancing the literature to identify relevant ethical, legal, or social concerns and solutions to those problems likely requires greater attention to specific applications of genetic or genomic tools to particular psychiatric disorders and associated behaviors/symptoms as well as broad stakeholder engagement.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10730-021-09465-5.

Reconsidering research exclusion for serious mental illness: Ethical principles, current status, and recommendations

BACKGROUND

Historically, individuals managing serious mental illness (SMI) have often been excluded from research, typically because of concern that these individuals may not be able to understand and provide truly informed consent. As treatment has improved, the assumption that individuals managing SMI may not be capable of consent needs to be re-examined. Systematic exclusion from research may limit empirically tested treatments available for people managing SMI, and may contribute to the health care disparities seen in this population.

OBJECTIVES

This article examines this issue by documenting current rates of research exclusion for high disease burden conditions, based on empirical review of studies in ClinicalTrials.gov.

RESEARCH DESIGN

Current rates of exclusion from studies for psychiatric conditions were assessed through systematic review of relevant clinical trials on ClinicalTrials.gov.

SUBJECTS

Subjects in this inquiry are either articles accessed in the literature reviews, or descriptions of studies in public data on ClinicalTrials.gov.

MEASURES

The primary measure was a previously published coding system to document the extent and types of research exclusion related to psychiatric status.

RESULTS

Among studies of interventions for substance use disorders and chronic pain, individuals managing SMI were more likely to be excluded than those with other psychiatric disorders at statistically significant levels. This was not the case among studies of interventions for ischemic heart disease. In studies of substance use disorders, 9% explicitly excluded SMI and 83% could exclude people with SMI based on broader exclusion criteria. In studies of chronic pain these two categories of exclusion were 16% and 55%, and in studies of ischemic heart disease, these two categories of exclusion were 1% and 20%.

CONCLUSIONS

Evidence indicates that it is ethically and scientifically more appropriate to exclude based on capacity to consent than membership in the group of individuals managing SMI. The discussion outlines techniques researchers can use for more equitable and generalizable sampling.

Perceived barriers to assessing understanding and appreciation of informed consent in clinical trials: A mixed-method study

Introduction:

Participants and research professionals often overestimate how well participants understand and appreciate consent information for clinical trials, and experts often vary in their determinations of participant’s capacity to consent to research. Past research has developed and validated instruments designed to assess participant understanding and appreciation, but the frequency with which they are utilized is unknown.

Methods:

We administered a survey to clinical researchers working with older adults or those at risk of cognitive impairment (N = 1284), supplemented by qualitative interviews (N = 60).

Results:

We found that using a validated assessment of consent is relatively uncommon, being used by only 44% of researchers who had an opportunity. Factors that predicted adoption of validated assessments included not seeing the study sponsor as a barrier, positive attitudes toward assessments, and being confident that they had the resources needed to implement an assessment. The perceived barriers to adopting validated assessments of consent included lack of awareness, lack of knowledge, being unsure of how to administer such an assessment, and the burden associated with implementing this practice.

Conclusions:

Increasing the use of validated assessments of consent will require educating researchers on the practice and emphasizing very practical assessments, and may require Institutional Review Boards (IRBs) or study sponsors to champion the use of assessments.

Decisional capacity determination and serious mental illness in oncology: Implications for equitable and beneficent care

BACKGROUND

Patients with Serious Mental Illness (SMI) have worse survival compared to cancer patients without SMI after controlling for delayed diagnosis. Decision-making capacity (DMC) may be impaired in both populations (cancer or SMI). DMC may be further impaired based on coupled vulnerability factors that challenge Shared Decision Making (SDM) for patients with cancer and SMI.

METHODS

Psychiatric consultations for DMC in hospitalized patients with cancer (n = 97) were consecutively evaluated across a single institution cancer center. SMI data, demographic, and cancer-related variables were obtained from the medical record. Descriptive data were contrasted in patients with and without DMC and used for logistic regression modeling.

RESULTS

Overall, 42% had DMC with no significant differences based on SMI (χ²  = 2.60, p = 0.11). Patients with SMI were younger, receiving anticancer treatment, and were less likely facing end of life issues. Age (OR 1.03, p = 0.05) and no recent anticancer treatments (OR 0.34, p = 0.02) were associated with decisional incapacity. At 3 months post discharge, almost two-thirds were dead with no difference based on SMI (χ²  = 0.01, p = 0.91). But End of Life (EOL) concerns were documented in 63% of non-SMI patients and only 36% of SMI patients (χ²  = 5.63, p = 0.02). Healthcare proxy (16%), four determinates of DMC (22%), and repeated psychiatric DCM assessments (35%) were documented with no differences based on SMI.

CONCLUSION

SDM is not equitable for cancer patients with SMI. Advanced directives and a robust effort to provide value-congruent care for patient with SMI who develop cancer may lessen this health inequity for cancer patients with SMI.

How Shared Is Shared Decision Making? Reaching the Full Potential of Patient-Clinician Collaboration in Mental Health

Shared decision making in mental health is a priority for stakeholders, but faces significant implementation barriers, particularly in settings intended to serve people with serious mental illnesses (SMI). As a result, current levels of shared decision making are low. We highlight these barriers and propose that a novel paradigm, collaborative decision making, will offer conceptual and practical solutions at the systemic and patient/clinician level. Collaborative decision making is tailored for populations like people with SMI and other groups who experience chronic and complex symptoms, along with power imbalances within health systems. Advancing from shared decision making to collaborative decision making clarifies the mission of the model: to facilitate an empowering and recovery-oriented decision-making process that assigns equal power and responsibility to patients and clinicians; to improve alignment of treatment decisions with patient values and priorities; to increase patient trust and confidence in clinicians and the treatment process; and, in the end, to improve treatment engagement, satisfaction, and outcomes. The primary purpose of collaborative decision making is to increase values-aligned care, therefore prioritizing inclusion of patient values, including cultural values and quality of life-related outcomes. Given the broad and constantly changing context of treatment and care for many people with SMI (and also other groups), this model is dynamic and continuously evolving, ready for use across diverse contexts. Implementation of collaborative decision making includes increasing patient knowledge but also patient power, comfort, and confidence. It is one tool to reshape patient-clinician and patient-system relationships and to increase access to value-aligned care for people with SMI and other groups.

What Is the Capacity of Individuals with Schizophrenia and Bipolar Disorder to Make Healthcare Decisions? An Exploratory Study of the Views of Patients, Psychiatrists, and Family Caregivers—A Survey on Decisional Capacity in Mental Health

Background: Research on the decisional capacity of schizophrenia and bipolar disorder patients mostly reflects the hospital context. Aim: To describe the views of patients, psychiatrists, and caregivers on the capacity of individuals with schizophrenia and bipolar disorder to make everyday decisions on their care related to their illness. Methods: A survey was conducted among schizophrenia and bipolar disorder patients, psychiatrists, and caregivers (June 2019 to January 2020; seven countries). A questionnaire was emailed to members of the Global Alliance of Mental Illness of Advocacy Network—Europe (GAMIAN; patients) and the European Federation of Families of People with Mental Illness (EUFAMI; caregivers) and to psychiatrists who voluntarily agreed to participate. Questions referred to patients’ involvement and capacity for healthcare decision making, and to barriers to and opportunities for autonomous decision making. Frequency, agreement, and importance were rated on Likert scales. Descriptive statistics were conducted. Results: 21 schizophrenia or bipolar disorder patients (52.3% female; mean age (years) ± SD: 50.71 ± 12.02), 11 psychiatrists (18.2% female), and 15 caregivers (86.6% female; 100% family related) participated in the survey. In total, 86% of patients felt frequently involved in decisions about everyday care and medications, and 91% of psychiatrists and 40% of caregivers perceived the same; 38% of patients felt frequently involved in decisions about the use of acute symptom medications, and 57% on care planning, and 55% and 82% of psychiatrists, and 40% and 53% of caregivers, respectively, believed the same; and 86% of patients, 91% of psychiatrists, and 47% of caregivers agreed on the capacity of schizophrenia or bipolar disorder patients to value the implications of taking medicines to prevent acute psychotic crises. Poor understanding and training are barriers, while advocacy and increasing interest in patients’ needs are opportunities for increasing autonomous decision making. Conclusions: Stakeholders concur that schizophrenia and bipolar disorder patients have the capacity to make everyday decisions around their care related to their illness, including acute symptom management. Barriers and opportunities exist to foster autonomous decisions among mental illness individuals.

An assessment of voting knowledge and related decisions amongst hospitalised mental healthcare users in South Africa

Background

The South African Constitution protects the right to vote for every citizen. The Electoral Act (No. 73 of 1998) limits registration on the voter’s roll on the basis of being declared of ‘unsound mind’ or ‘mentally disordered’ by the high court or detention under the Mental Health Care Act (No. 17 of 2002). There is limited information regarding voting knowledge and subsequent voting-related decisions amongst South African involuntary mental healthcare users (MHCUs).

Aim

To compare voting knowledge and related decisions between hospitalised MHCUs and non-psychiatric hospitalised patients (controls).

Setting

Participants were recruited from Sterkfontein Psychiatric Hospital (MHCUs) and Chris Hani Baragawanth Academic Hospital orthopaedic wards (controls) in Gauteng, South Africa.

Method

A cross-sectional survey was conducted using a modified Cognitive Assessment Tool for Voting (MCAT-V) questionnaire. Scores on the MCAT-V were compared between the MHCU and control groups, along with socio-demographic variables and clinical variables.

Results

There was a significant association between group (MHCU vs. control) and HLOE (p = 0.016). Although the median overall score for the controls (11; interquartile range [IQR] 10–12) was significantly higher than that for the MHCUs (10; IQR 8–12) (p = 0.043), when controlling for education level, there was no significant association between group (MHCU/control) and MCAT-V scores (p = 0.011). The MCAT-V scores of the ‘Doe questions’ between the MHCUs and controls were not significantly different (p = 0.063). There was a difference in ‘reasoning scores’ between MHCUs and controls (p = 0.0082) and this was associated with level of educational attainment (p = 0.013).

Conclusion

The limitations regarding voter registration legislated in the South African Electoral Act, are not supported by the findings of this study. The MCAT-V demonstrates a possible educational bias and therefore is not recommended as a screening tool for assessing voting competency.

Decision Making in Psychiatric Patients: A Qualitative Study with Focus Groups

INTRODUCTION

It has been said that mental illnesses are characterised by poor decision making; there is some neuroscientific evidence of specific alterations in performance in decision making tests, but little is known about how patients make choices about their own treatments.

METHODS

Focus groups with patients from two psychiatric clinics, with discourse analysis.

RESULTS

Five deductive categories (tools, capacity, therapeutic relationship, method and family and network), plus one additional category from the analysis (stigma), and 35 inductive (posterior) categories were considered. The categories are analysed and the findings presented.

CONCLUSIONS

Patients express a need for greater participation in decisions about their treatment, and a more symmetrical psychiatrist-patient relationship, involving families. Decisions may be changed due to stigma, barriers to treatment access, and previous experiences.

Mental health professionals' experiences with shared decision-making for patients with psychotic disorders: a qualitative study

BACKGROUND

Shared decision-making (SDM) is a process whereby clinicians and patients work together to select treatments based on both the patient's preferences and clinical evidence. Although patients with psychotic disorders want to participate more in decisions regarding their care, they have limited opportunities to do so because of various barriers. Knowing about health professionals' experiences with SDM is important toward achieving successful implementation. The study aim was to describe and explore health professionals' SDM experiences with patients with psychotic disorders.

METHODS

Three focus group interviews were conducted, with a total of 18 health professionals who work at one of three Norwegian community mental health centres where patients with psychotic disorders are treated. We applied a descriptive and exploratory approach using qualitative content analysis.

RESULTS

Health professionals primarily understand the SDM concept to mean giving patients information and presenting them with a choice between different antipsychotic medications. Among the barriers to SDM, they emphasized that patients with psychosis have a limited understanding of their health situation and that time is needed to build trust and alliances. Health professionals mainly understand patients with psychotic disorders as a group with limited abilities to make their own decisions. They also described the concept of SDM with little consideration of presenting different treatment options. Psychological or social interventions were often presented as complementary to antipsychotic medications, rather than as an alternative to them.

CONCLUSION

Health professionals' understanding of SDM is inconsistent with the definition commonly used in the literature. They consider patients with psychotic disorders to have limited abilities to participate in decisions regarding their own treatment. These findings suggest that health professionals need more theoretical and practical training in SDM.

Treatment Capacity and Clinical Outcomes for Patients With Schizophrenia Who Were Treated With Electroconvulsive Therapy: A Retrospective Cohort Study

BACKGROUND

Patients with schizophrenia are often found incapable to consent to psychiatric treatment. We evaluated clinical outcomes for incapable and capable patients with schizophrenia treated with electroconvulsive therapy (ECT).

METHODS

We conducted a chart review of all inpatients treated with an acute course of ECT between 2010 and 2018 at the Centre for Addiction and Mental Health, Toronto, Canada. Short-term outcomes included treatment response and cognitive impairment. We assessed whether incapable patients regained the capacity to consent to treatment. Long-term outcomes included readmissions and subsequent courses of acute or maintenance ECT.

RESULTS

A total of 159 (67%) incapable and 79 (33%) capable patients were included. Patients experienced treatment response (incapable, n = 108, 67.9%; capable, n = 52, 65.8%; P = .771) and few experienced cognitive impairment (incapable, n = 21, 13.2%; capable, n = 19, 24.1%; P = .043). A minority of patients were treated with a subsequent course of acute ECT (incapable, n = 46, 28.9%; capable, n = 16, 20.3%; P = .162). Incapable patients were more likely to be treated with maintenance ECT for at least 6 months (incapable, n = 46, 28.9%; capable, n = 13, 16.5%; P = .039). Both groups had similar readmission rates (incapable, n = 70, 44.0%; capable, n = 35, 44.3%; P = 1.000). Eight (5.0%) incapable patients regained capacity and 7 consented to further treatment.

CONCLUSIONS

Irrespective of treatment capacity, the majority of patients demonstrated clinical improvement. Incapable patients experienced less cognitive side effects when compared with capable patients, though they had fewer treatments overall. This study informs clinicians, patients, and substitute decision-makers about the outcomes and challenges of ECT in patients with schizophrenia.

A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare

BACKGROUND

Determining the mental capacity of psychiatric patients for making healthcare related decisions is crucial in clinical practice. This meta-review of review articles comprehensively examines the current evidence on the capacity of patients with a mental illness to make medical care decisions.

METHODS

Systematic review of review articles following PRISMA recommendations. PubMed, Scopus, CINAHL and PsycInfo were electronically searched up to 31 January 2020. Free text searches and medical subject headings were combined to identify literature reviews and meta-analyses published in English, and summarising studies on the capacity of patients with serious mental illnesses to make healthcare and treatment related decisions, conducted in any clinical setting and with a quantitative synthesis of results. Publications were selected as per inclusion and exclusion criteria. The AMSTAR II tool was used to assess the quality of reviews.

RESULTS

Eleven publications were reviewed. Variability on methods across studies makes it difficult to precisely estimate the prevalence of decision-making capacity in patients with mental disorders. Nonetheless, up to three-quarters of psychiatric patients, including individuals with serious illnesses such as schizophrenia or bipolar disorder may have capacity to make medical decisions in the context of their illness. Most evidence comes from studies conducted in the hospital setting; much less information exists on the healthcare decision making capacity of mental disorder patients while in the community. Stable psychiatric and non-psychiatric patients may have a similar capacity to make healthcare related decisions. Patients with a mental illness have capacity to judge risk-reward situations and to adequately decide about the important treatment outcomes. Different symptoms may impair different domains of the decisional capacity of psychotic patients. Decisional capacity impairments in psychotic patients are temporal, identifiable, and responsive to interventions directed towards simplifying information, encouraging training and shared decision making. The publications complied satisfactorily with the AMSTAR II critical domains.

CONCLUSIONS

Whilst impairments in decision-making capacity may exist, most patients with a severe mental disorder, such as schizophrenia or bipolar disorder are able to make rational decisions about their healthcare. Best practice strategies should incorporate interventions to help mentally ill patients grow into the voluntary and safe use of medications.

Adult Vaccination Rates in the Mentally Ill Population: An Outpatient Improvement Project

Background: Adults who suffer with severe and persistent mental illness (SPMI) rarely access medical care to receive preventive vaccines. Aims: To increase the rate of vaccines among the SPMI population in an outpatient community mental health center (CMHC). Methods: A review of the literature identified a gap between the general population and SPMI clients in receiving preventive vaccinations. An initial mixed-method convenience survey of SPMI clients (n = 392) provided information on current vaccination status, demographics, beliefs, and interest in receiving vaccines. A vaccination program was developed to address identified barriers and increase vaccination rates. Postintervention data were collected through a mixed-method convenience survey of SPMI clients (n = 60) who participated in immunizations clinics to evaluate client satisfaction. A partnership between the health department and CMHC was developed to deliver vaccines in a nontraditional site. Vaccines administered included annual influenza; hepatitis A; hepatitis B; herpes zoster; measles, mumps, and rubella; pneumococcal; and tetanus, diphtheria, and pertussis (Tdap). Results: More than 1,000 vaccines were administered in the first 8 months, with a significant increase in vaccination rates over baseline for individual vaccines ranging from 18.75% to 83%. Postintervention survey results found a 95% satisfaction rate. Conclusions: Implementation of a vaccination program in a nontraditional site that facilitates access for SPMI clients can promote an overwhelming increase in the vaccination rates for this underserved population. Results suggest that the integration of mental health and CMHC services can have a profound positive effect on SPMI population health.

Decisional capacity to consent to treatment and anaesthesia in patients over the age of 60 undergoing major orthopaedic surgery

Despite growing attention to the ability of patients to provide informed consent to treatment in different medical settings, few studies have dealt with the issue of informed consent to major orthopaedic surgery in those over the age of 60. This population is at risk of impaired decision-making capacity (DMC) because older age is often associated with a decline in cognitive function, and they often present with anxiety and depressive symptoms, which could also affect their capacity to consent to treatment. Consent to major orthopaedic surgery requires the patient to understand, retain and reason about complex procedures. This study was undertaken to extend the literature on decisional capacity to consent to surgery and anaesthesia of patients over the age of 60 undergoing major orthopaedic surgery. Recruited patients ( N=83) were evaluated using the Aid to Capacity Evaluation, the Beck Depression Inventory, the State–Trait Anxiety Inventory Y, the Mini-Mental State Examination and a visual analogue scale for measuring pain symptomatology. Impairment of medical DMC was common in the overall sample, with about 50% of the recruited patients showing a doubtful ability, or overt inability, to provide informed consent. Poor cognitive functioning was associated with reduced medical DMC, although no association was found between decisional capacity and depressive, anxiety and pain symptoms. These findings underline the need of an in-depth assessment of capacity in older patients undergoing major orthopaedic surgery.

Questionnaire on Attitude towards Research and Care (QuARC): a survey of patients with psychosis

Background: The patients' appraisal, satisfaction and attitude toward research is crucial to obtain reliable information, in psychiatry frequently not objective.Aim: We operationalised the information derived from studies on satisfaction and attitude towards research and developed a standardized measure, whose internal consistency and factor structure was investigated.Method: The Questionnaire on Attitude towards Research and health Care (QuARC) is a 10-item self-report scale, administered to 116 patients with psychotic disorders participating in research protocols. Exploratory factor analysis was conducted and internal consistency evaluated.Results: Two factors have been identified: one labelled External Factor, including items related to information on the received treatment, relationship with third parties, and one labelled Internal Factor with items related to the disorder, perceived well-being and contribution to scientific knowledge. Cronbach's alpha internal consistencies were good.Conclusions: The QuARC is easy to use, well accepted, with good psychometric properties. The constructs identified are different from the original issues addressed (i.e. attitude and satisfaction), prevailing different constructs closer to the patient opinion on the research and personal condition. These constructs identify dimensions useful to delineate and understand the patients' experience of participating in a scientific project as well as their satisfaction.

Competence to Consent and Its Relationship With Cognitive Function in Patients With Schizophrenia

Decisional capacity to consent is an emerging ethical and legal concept, and is closely related to self-determination of patients facing important medical decisions or research participations. Recently, the MacArthur Competence Assessment Tool (MacCAT), a semi-structured interview consisting of four dimensions (Understanding, Appreciation, Reasoning, and Expression of a Choice), was developed to assess the decisional capacity. Decision-making capacity in a group of patients with schizophrenia, as measured by the MacCAT, has been shown to be impaired in comparison with healthy control people. However, this does not necessarily mean the presence of impaired decisional capacity in all cases. Considering the real-world practice of obtaining informed consent from patients with schizophrenia, it is important to evaluate the relationship between psychopathological features and decisional capacity of the illness. Negative symptoms of schizophrenia have been demonstrated to be related to the ability to understand information relevant to the decision, reason rationally, and appreciate a situation and its consequences. On the other hand, positive symptoms, such as delusions and hallucinations have been an inconsistent correlate of poor capacity. Furthermore, some studies indicate that impairment of cognitive function, a core symptom of schizophrenia, could be more largely associated with decisional capacity than positive and negative symptoms. Therefore, it is reasonable to assume cognitive enhancement would enlarge the capacity to consent and promote autonomy in medical treatment and research participation in patients with schizophrenia. Further studies are warranted to elucidate this and related issues.

Does informed consent given by healthy individuals when enrolling in clinical research feel less voluntary than for ill individuals?

Clinical research is predicated ethically on the authentic voluntarism of individuals who choose to enroll in human studies. Existing literature has focused on aspects of informed consent for clinical research other than voluntarism. The objective of this study was to compare the perspectives of clinical research participants who are in good health and who are ill regarding voluntarism-related aspects of informed consent and to assess situational influences that enable voluntarism in the process of obtaining clinical research consent. A 23-item written survey, the Informed Consent Questionnaire (ICQ), was administered in a "piggyback" semi-structured interview study of ill and healthy volunteers enrolled in IRB-approved clinical research studies. A total of 150 (60 mentally ill, 43 physically ill, and 47 healthy) clinical research participants participated. Respondents expressed positive views of their experiences with the informed consent processes for their respective clinical research protocols and respondents strongly endorsed items related to voluntarism irrespective of their illness type (range of means = [3.9, 4.8]). Ill participants more highly endorsed items relating to informed consent conditions (mentally ill vs healthy: 0.54 on a 5-point scale, P value = 0.01) (physically ill vs. healthy: 0.47 on a 5-point scale, P value = 0.01). The favorable views of clinical research participants regarding their experience of giving informed consent to enroll in a study were not surprising. Contrary to our a priori hypothesis, healthy individuals did not feel as positively as their ill counterparts.

Decision-making Capacity for Treatment of Psychotic Patients on Long Acting Injectable Antipsychotic Treatment

OBJECTIVE

Providing informed, consent requires patients' Decision-Making Capacity for treatment. We evaluated the Decision Making Capacity of outpatients diagnosed with schizophrenia and schizoaffective disorder on treatment with Long Acting Injectable Antipsychotic medication.

METHOD

This is a retrospective, cross-sectional, correlational study conducted at two Depot Clinics in Athens, Greece. Participants included 65 outpatients diagnosed with schizophrenia and schizoaffective disorder on treatment with Long Acting Injectable Antipsychotics.

RESULTS

Over half of the participants showed poor understanding of the information given regarding their disease and treatment (Understanding subscale), however >70% seemed to comprehend the relevance of this information to their medical condition (Appreciation subscale). Moreover, half of the participants reported adequate reasoning ability (Reasoning subscale), whilst patients who gained >7% of their body weight scored statistically significantly higher in the subscales of Understanding and Appreciation.

CONCLUSION

Our results suggest that there is a proportion of patients with significantly diminished Decision Making Capacity, hence a full assessment is recommended in order to track them down. Further research is needed to better interpret the association between antipsychotic induced weight gain and Decision Making Capacity in patients suffering from schizophrenia or schizoaffective disorder.

Testing decision-making competency of schizophrenia participants in clinical trials. A meta-analysis and meta-regression

BACKGROUND

The process of assessing the decision-making capacity of potential subjects before their inclusion in clinical trials is a legal requirement and a moral obligation, as it is essential for respecting their autonomy. This issue is especially important in psychiatry patients (such as those diagnosed with schizophrenia). The primary purpose of this article was to evaluate the degree of impairment in each dimension of decision-making capacity in schizophrenia patients compared to non-mentally-ill controls, as quantified by the (MacCAT-CR) instrument. Secondary objectives were (1) to see whether enhanced consent forms are associated with a significant increase in decision-making capacity in schizophrenia patients, and (2) if decision-making capacity in schizophrenia subjects is dependent on the age, gender, or the inpatient status of the subjects.

METHODS

We systematically reviewed the results obtained from three databases: ISI Web of Science, Pubmed, Scopus. Each database was scrutinised using the following keywords: "MacCAT-CR + schizophrenia", "decision-making capacity + schizophrenia", and "informed consent + schizophrenia."

RESULTS

We included 13 studies in the analysis. The effect size between the schizophrenia and the control group was significant, with a difference in means of -4.43 (-5.76; -3.1, p < 0.001) for understanding, -1.17 (-1.49, -0.84, p < 0.001) for appreciation, -1.29 (-1.79, -0.79, p < 0.001) for reasoning, and -0.05 (-0.9, -0.01, p = 0.022) for expressing a choice.

CONCLUSIONS

Even if schizophrenia patients have a significantly decreased decision-making capacity compared to non-mentally-ill controls, they should be considered as competent unless very severe changes are identifiable during clinical examination. Enhanced informed consent forms decrease the differences between schizophrenia patients and non-mentally-ill controls (except for the reasoning dimension) and should be used whenever the investigators want to include more ill patients in their clinical trials. Increased age, men gender and an increased percentage of inpatients might increase the differential of decision-making incompetence compared to non-mentally-ill subjects in various dimensions of the decision-making competence as analysed by the MacCAT-CR scale, but the small number of subjects did not allow us (except for one instance) to reach statistical significance.

Multimedia Aided Consent for Alzheimer's Disease Research

OBJECTIVES

Optimizing the research consent process simultaneously fosters respect for autonomy and protection of those with diminished capacity for autonomy. This study evaluated the effectiveness of an enhanced research consent procedure, employing multimedia disclosure and corrective feedback, in improving decisional capacity among 114 people with mild-to-moderate Alzheimer's disease (AD) and 134 non-psychiatric comparison (NC) subjects.

METHODS

Participants were randomized to consent type (routine versus enhanced) and protocol type (lower versus higher risk). Outcomes included a 5-item questionnaire assessing immediate comprehension, MacArthur Competence Assessment Tool for Clinical Research assessing four components of decision-making capacity, and categorical decisional capacity (based on a cut-score established in reference to expert judgments for a subset of participants).

RESULTS

There was no significant effect of the enhanced consent procedure, relative to routine consent, on immediate comprehension or decisional capacity.

CONCLUSIONS

Multimedia tools do not appear to be the solution to better consent for AD research.

CLINICAL IMPLICATIONS

Given the ethical primacy of informed consent and issues of justice for impaired populations who might be harmed by an absence of research-based treatment advances, continued search for ways to more meaningfully engage people with AD in the consent or assent process is warranted.

Spanish Validation of the MacArthur Competence Assessment Tool for Clinical Research Interview for Assessing Patients' Mental Capacity to Consent to Clinical Research

The aim of the study was to assess a Spanish adaptation of a method that determines the categorical capacity status of potential participants in research projects. The sample consisted of 120 subjects (40 general medicine inpatients, 40 psychiatric inpatients, and 40 healthy controls). The MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) interview and Mini-Mental State Examination (MMSE) were used. A feasibility study was carried out and reliability and validity calculations were made against the expert-judgment gold standard. The mean duration of the MacCAT-CR was 13 min. For the MacCAT-CR understanding, appreciation, reasoning, and expressing a choice subscales, the intraclass coefficient correlation (interrater reliability) was .93, .88, .90, and .50, respectively, and internal consistency (Cronbach's alpha) was .96, .94, and .95, respectively. Patients considered to be incompetent for expert-judgment obtained lower scores in the MacCAT-CR interview. The Spanish version of the MacCAT-CR is feasible, reliable, and valid for assessing the capacity of patients to give consent in research.

Diversity or disarray? A systematic review of decision-making capacity for treatment and research in schizophrenia and other non-affective psychoses

BACKGROUND

Valid consent for treatment or research participation requires that an individual has decision-making capacity (DMC), which is the ability to make a specific decision. There is evidence that the psychopathology of schizophrenia can compromise DMC. The objective of this review was to examine the presence or absence of DMC in schizophrenia and the socio-demographic/psychopathological factors associated.

METHODS

We searched three databases Embase, Ovid MEDLINE(R), and PsycINFO for studies reporting data on the proportion of DMC for treatment and research (DMC-T and DMC-R), and/or socio-demographic/psychopathological associations with ability to make such decisions, in people with schizophrenia and related illnesses.

RESULTS

A total of 40 studies were identified. While high levels of heterogeneity limited direct comparison, meta-analysis of inpatient data showed that DMC-T was present in 48% of people. Insight was strongly associated with DMC-T. Neurocognitive deficits were strongly associated with lack of DMC-R and to a lesser extent DMC-T. With the exception of years of education, there was no evidence for an association with socio-demographic factors.

CONCLUSIONS

Insight and neurocognitive deficits are most closely associated with DMC in schizophrenia. The lack of an association with socio-demographic factors dispels common misperceptions regarding DMC and characteristics such as age. Although our results reveal a wide spectrum of DMC-T and DMC-R in schizophrenia, this could be partly due to the complexity of the DMC construct and the heterogeneity of existing studies. To facilitate systematic review research, there is a need for improvement within research study design and increased consistency of concepts and tools.

The MacArthur Competence Assessment Tools for assessing decision-making capacity in schizophrenia: A meta-analysis

OBJECTIVE

This meta-analysis aimed to examine the decisional capacity measured by the MacArthur Competence Assessment Tools (MacCAT) in schizophrenia.

METHOD

English (PubMed, PsycINFO, Embase, Cochrane Library databases and the Cochrane Controlled Trials Register) and Chinese (Wan Fang Database and Chinese National Knowledge Infrastructure) databases were systematically and independently searched from 1995 until August 1, 2016. Weighted and standardized mean differences were calculated. The random effects model was used in all cases.

RESULTS

Altogether 10 studies were identified, with 7 studies using the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and 3 studies using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). The meta-analysis showed that there was significant impairment in decision-making capacity in schizophrenia patients compared to the healthy control group in terms of Understanding (SMD=-0.81, 95% CI: -1.06 to -0.56, P<0.001), Reasoning (SMD=-0.57, 95% CI: -0.80 to -0.34, P<0.001), Appreciation (SMD=-0.87, 95% CI: -1.20 to -0.53, P<0.001), and Expression a choice (SMD=-0.24, 95% CI: -0.43 to -0.05, P=0.01).

CONCLUSION

Compared to the control group, schizophrenia patients are more likely to have impaired decision-making capacity in clinical research and treatment as measured by the MacCAT instruments. Researchers and clinicians need to consider the impaired decisional capacity in schizophrenia patients providing informed consent.

Healthy individuals' perspectives on clinical research protocols and influences on enrollment decisions

BACKGROUND

Understanding the perspectives of healthy individuals is important ethically and for the advancement of science. We assessed perceptions of risk associated with research procedures, comparing views of healthy individuals with and without experience in clinical research, and the respondents' reported willingness to volunteer.

METHODS

Semistructured interviews and written surveys were conducted. Study participants were healthy individuals, half of whom were currently enrolled in clinical research and half of whom had no prior experience in clinical research. Participants were queried regarding seven "minimal risk" or "greater than minimal risk" protocol vignettes with procedures of three types: routine diagnostic tests, more burdensome (i.e., more effort or potential harm) diagnostic tests, and pharmacologic interventions. Views of influences on enrollment decisions were also assessed.

RESULTS

Most healthy individuals indicated that protocols with more burdensome or pharmacologic interventions were very risky (59%, 58%), as opposed to routine diagnostic test procedures (32%). Respondents' willingness to enroll in protocols varied by type of protocol (p value < .001) and was inversely correlated with risk assessments (regression coefficients from GEE = -0.4; -0.5; -0.7). The odds of healthy individuals with research experience expressing strong willingness to enroll in the depicted protocols were twice the odds of healthy individuals without research experience expressing the same level of willingness (OR = 2.0 95% CI: [1.1, 3.9]). Respondents did not assign risk categories as institutional review boards (IRBs) would, as indicated by low agreement (26%) between respondent and expert opinion on minimal risk protocols.

CONCLUSIONS

Perceptions of procedure risk appear to influence healthy individuals' willingness to enroll in protocols. Participants with experience in clinical research were far more likely to express willingness to enroll, a finding with important scientific and ethical implications. The lack of alignment between healthy individuals' views of protocol risk and IRB categorization warrants further study.

Enhancing the informed consent process in psychiatric outpatients with a brief computer-based method

Informed consent is a key element of ethical clinical research. Those with mental disorders may be at risk for impaired consent capacity. Problems with procedures may also contribute to patient's ´difficulties in understanding consent forms. The present investigation explores if a brief technologically based information presentation of the informed consent process may enhance psychiatric patients understanding and satisfaction. In this longitudinal, within-participants comparison study, patients who initially were judged to lack capacity to make research decisions (n=41) and a control group (n=47) were followed up. Decisional capacity, willingness to participate and cognitive and clinical scores were assessed at baseline and after receiving the computer-assisted enhanced consent. With sufficient cueing, patients with impaired research-related decision-making capacity at baseline were able to display enough understanding of the consent form. Patient satisfaction and willingness to participate also increased at follow up. Implications of these results for clinical practice and medical research involving people with mental disorders are discussed.

The struggle for schizophrenia treatment: A case study

Individual of legal age with schizophrenia presenting anosognosia was abandoned, as a result of a court decision. Close family members were not allowed to provide medical follow-up, treatment, protection regarding his vulnerability, and preserve the dignity of their loved one. The issue was the court's prioritization of the autonomy of the individual over his mental health status. The purpose of this case study was to identify the pitfalls of a court case seeking medical follow-up and treatment for a family member with schizophrenia and anosognosia. The method was qualitative and the design was descriptive and instrumental, linking the law to the life experience resulting from the procedures for its implementation. This study examined the difference between clinical and medical-legal evaluation of the examinee. The application of the Therapeutic Jurisprudence principles to the high number of schizophrenia cases with anosognosia, the abandonment of the mentally ill, and family crisis call healthcare providers and the Judiciary for an improvement action of the process of guardianship.

Psychopathology, psychopharmacological properties, decision-making capacity to consent to clinical research and the willingness to participate among long-term hospitalized patients with schizophrenia

Many studies discuss factors related to the decision-making capacity to consent to clinical research (DMC) of patients with schizophrenia. However, these studies rarely approached willingness to participate and the association between psychopharmacological properties (e.g., antipsychotic-induced side effects) and DMC. This study aimed to explore factors related to DMC and willingness to participate in patients with schizophrenia. All 139 patients with schizophrenia were assessed with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and other measures. A linear regression model was used to find the predictors of MacCAT-CR scores. A logistic regression model was used for exploring the predictors of willingness to participate. Patients with more severe negative symptoms performed poorly in DMC outcomes. In addition, females, those with fewer years of education and reduced cognitive function are more likely to experience difficulties in decision-making. Forty-three subjects (30.4%) chose to participate. Patients with higher level of positive symptoms, longer length of stay, higher burden of anticholinergics and users of atypical antipsychotics were more likely to participate in a clinical study which aimed to "enhance cognition". These finding suggest that research investigators should consider many variables for patients who require more intensive screening for impaired DMC.

Assessment of Capacity to Consent to Research Among Psychiatric Outpatients: Prevalence and Associated Factors

Mental capacity is an emerging ethical legal concept in psychiatric settings but its relation to clinical parameters remains yet uncertain. The aim of this study is to evaluate the association between capacity to consent research and different psychiatric disorders and to characterize predictors of impairments in research decision-making capacity across diagnostic groups in a cross-sectional study. 139 consecutively referred outpatients with DSM-IV TR diagnoses of psychotic, mood and anxiety disorders were interviewed and a binary judgment of incapacity was made guided by the MacArthur competence assessment tool for consent research (MacCAT-CR). Demographics and clinical information were assessed by cases notes. Patients with anxiety disorders performed the best on the MacCAT-CR, and patients with psychotic disorders had the worst performance, however, there was considerable heterogeneity within each group. Cognitive impairment and global functioning were strongly correlated with MacCAT-CR subscales scores. 30.6% participants lacked research-related decisional capacity. Low Understanding score OR 0.07 (IC 95% 0.01-0.32) and Low Reasoning score OR 0.30 (IC 95% 0.11-0.82) were the factors most closely associated with lack of capacity. No absolute statements about decisional capacity can be driven merely due to the diagnosis. We found several risk factors which may be considered to decide which populations may require more thorough capacity assessments. The issues under consideration in the present study are by no means unique to people with psychiatric conditions. Ignoring this caveat, risks further inappropriate stigmatization of those with serious mental illness.

Customising informed consent procedures for people with schizophrenia in India

BACKGROUND

There is little information on how the ethical and procedural challenges involved in the informed participation of people with schizophrenia in clinical trials are addressed in low- and middle-income countries (LMICs). The informed consent procedure used in the collaborative community care for people with schizophrenia in India (COPSI) RCT was developed keeping these challenges in mind. We describe the feasibility of conducting the procedure from the trial, researcher and participants perspectives and describe the reasons for people consenting to participate in the trial or refusing to do so.

METHODS

Three sources of information were used to describe the feasibility of the COPSI consent procedure: key process indicators for the trial perspective, data from a specially designed post-interview form for participant's observations and focus group discussion (FGD) with the research interviewers. Categorical data were analysed by calculating frequencies and proportions, while the qualitative data from the FGD, and the reasons for participation or refusal were analysed using a thematic content analysis approach.

FINDINGS

434 people with schizophrenia and their primary caregiver(s) were approached for participation in the trial. Consent interviews were conducted with 332, of whom 303 (91%) agreed to participate in the trial. Expectation of improvement was the most common reason for agreeing to participate in the trial, while concerns related to the potential disclosure of the illness, especially for women, were an important reason for refusing consent.

CONCLUSIONS

The COPSI consent procedure demonstrates preliminary, observational information about the feasibility of customising informed consent procedures for people with schizophrenia LMIC contexts. This and other similar innovations need to be refined and rigorously tested to develop evidence-based guidelines for informed consent procedures in such settings.

Demonstrating Patterns in the Views Of Stakeholders Regarding Ethically-Salient Issues in Clinical Research: A Novel Use of Graphical Models in Empirical Ethics Inquiry

BACKGROUND

Empirical ethics inquiry works from the notion that stakeholder perspectives are necessary for gauging the ethical acceptability of human studies and assuring that research aligns with societal expectations. Although common, studies involving different populations often entail comparisons of trends that problematize the interpretation of results. Using graphical model selection - a technique aimed at transcending limitations of conventional methods - this report presents data on the ethics of clinical research with two objectives: (1) to display the patterns of views held by ill and healthy individuals in clinical research as a test of the study's original hypothesis and (2) to introduce graphical model selection as a key analytic tool for ethics research.

METHODS

In this IRB-approved, NIH-funded project, data were collected from 60 mentally ill and 43 physically ill clinical research protocol volunteers, 47 healthy protocol-consented participants, and 29 healthy individuals without research protocol experience. Respondents were queried on the ethical acceptability of research involving people with mental and physical illness (i.e., cancer, HIV, depression, schizophrenia, and post-traumatic stress disorder) and non-illness related sources of vulnerability (e.g., age, class, gender, ethnicity). Using a statistical algorithm, we selected graphical models to display interrelationships among responses to questions.

RESULTS

Both mentally and physically ill protocol volunteers revealed a high degree of connectivity among ethically-salient perspectives. Healthy participants, irrespective of research protocol experience, revealed patterns of views that were not highly connected.

CONCLUSION

Between ill and healthy protocol participants, the pattern of views is vastly different. Experience with illness was tied to dense connectivity, whereas healthy individuals expressed views with sparse connections. In offering a nuanced perspective on the interrelation of ethically relevant responses, graphical model selection has the potential to bring new insights to the field of ethics.

Patient-Centered Outcomes Research (PCOR): How Can We Optimize Outcomes in CNS Research?

Patient-centered outcomes research increases patient involvement in health-related decisions with better information of benefits, risks, and options as it pertains to patient health. Patient-centered outcomes research is valuable for improving patient options in general; however, the vulnerability of patients with certain central nervous system conditions and their variable capacity to consent may pose significant challenges. Methods/review: Authors acknowledge the historical issues and address needs regarding better dissemination of knowledge in central nervous system conditions like dementia, depression, and schizophrenia. Authors propose ethical safeguards necessary to carry out sound patient-centered outcomes research in this unique population. Discussion/recommendations: To facilitate ethical patient-centered outcomes research, researchers must 1) assess the individual's mental capacity to provide consent, 2) determine vulnerability and risk of conducting research in specific subgroups, and 3) consider appointment of legally authorized representatives and/or consent monitors to ensure accurate understanding of research and ongoing direct communication with patients, especially when their future prognosis is unpredictable.

Medical patients' treatment decision making capacity: a report from a general hospital in Greece

This study aimed to assess the decision-making capacity for treatment of patients hospitalized in an internal medicine ward of a General Hospital in Greece, and to examine the views of treating physicians regarding patients' capacity. All consecutive admissions to an internal medicine ward within a month were evaluated. A total of 134 patients were approached and 78 patients were interviewed with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the Mini Mental State Examination (MMSE) questionnaire. Sixty-eight out of 134 patients (50.7%) were incompetent to decide upon their treatment. The majority of them (n=56, 41.8%) were obviously incapable because they were unconscious, or had such marked impairment that they could not give their own names, and the rest (n=12, 8.9%) were rated as incompetent according to their performance in the MacCAT-T. Neurological disorders, old age and altered cognitive function according to MMSE were negatively correlated with decision making capacity. Physicians sometimes failed to recognize patients' incapacity. Rates of decision-making incapacity for treatment in medical inpatients are high, and incapacity may go unrecognized by treating physicians. Combined patient evaluation with the use of the MacCAT-T and MMSE, could be useful for the determination of incapable patients.

Capable of more: some underemphasized aspects of capacity assessment

BACKGROUND

The 4-abilities model of decision-making capacity is vulnerable to constricted application and teaching.

OBJECTIVE

The authors attempt to assert the fundamentally clinical nature of capacity evaluations, while acknowledging that the concept of decision-making capacity must be legally grounded.

METHODS

Relevant aspects of clinical care are examined and emphasized as they apply to the evaluation of capacity for medical decision making.

RESULTS

Accessing patients' maximal abilities, attending to noncognitive aspects of choice, and identifying diagnostic explanations for patients' difficulties are important components of these assessments.

DISCUSSION

The evaluation of medical decision-making capacity is not a purely forensic task; it is enhanced by an approach that bridges the clinical-forensic divide.

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.