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Di Fazio N, Morena D, Piras F, Piras F, Banaj N, Delogu G, Damato F, Frati P, Fineschi V, Ferracuti S, Sani G, Dacquino C. Reliability of clinical judgment for evaluation of informed consent in mental health settings and the validation of the Evaluation of Informed Consent to Treatment (EICT) scale. Front Psychol 2024; 15:1309909. [PMID: 38566948 PMCID: PMC10986368 DOI: 10.3389/fpsyg.2024.1309909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction The competence assessment to give informed consent in the legal and healthcare settings is often performed merely through clinical judgment. Given the acknowledged limited reliability of clinician-based evaluation in the mental health sector, particularly for the assessment of competence to consent, our objective was to ascertain the dependability of clinical judgment when evaluating the ability of schizophrenia patients to make choices about their health. Methods The potential convergence between clinical evaluation and scores from a new standardized assessment (the "Evaluation of Informed Consent to Treatment" - "EICT" scale) was therefore tested. The scale assesses four dimensions of competence, specifically how patients normally understand information relating to care (Understanding); how they evaluate the choice of treatment in terms of risk/benefit ratio (Evaluating); how they reason coherently in the decision-making process (Reasoning); and, finally, their ability to make a choice between treatment alternatives (Expressing a choice). Thirty-four outpatients with schizophrenia were evaluated for their competence to consent by five referring clinicians with different backgrounds (psychiatrist, forensic psychiatrist, geriatrician, anesthetist, and medico-legal doctor). Inter-raters variability was tested through correlation analyses between the scores obtained by the clinicians on a modified version of the Global Assessment of Functioning scale (GAF) designed specifically to subjectively assess functioning in each of the four competence dimensions. Two validated competence scales (Mac-CAT-T, SICIATRI-R), and a neuropsychological battery were also administered along with scales for evaluating neuropsychiatric symptoms severity and side effects of medication. Results Clinical judgments of the individual specialists showed great inter-rater variability. Likewise, only weak/non-significant correlations were found between the EICT subscales and the respective clinicians-rated GAF scales. Conversely, solid correlations were found between the EICT and MacCAT-T subscales. As expected, healthy controls performed better in the ability to give informed consent to treatment, as measured by the three scales (i.e., EICT, MacCAT-T, and SICIATRI-R), and neuropsychological test performance. In the comparisons between patients who, according to the administered EICT, were able or not able to give informed consent to treatment, significant differences emerged for the Phonemic verbal fluency task (p = 0.038), Verbal judgments (p = 0.048), MacCAT-T subscales, and SICIATRI-R total score. Moreover, EICT exhibited excellent internal consistency (Cronbach's alphas ranging from 0.96 to 0.98 for the four subscales) while the Item Analysis, by measuring the correlation between each item of the EICT and the total score, was excellent for all items of all subscales (alphas ranging from 0.86 to 0.98). Discussion In conclusion, our findings highlighted that the assessment of competence exclusively through clinical judgment is not fully reliable and needs the support of standardized tools. The EICT scale could therefore be useful in assessing general competence to consent both in healthcare and legal contexts, where it might be necessary to evaluate the effective competence of patients with psychiatric disorders. Finally, this scale could serve as a valuable tool for decisions regarding whether and to what extent a patient needs support.
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Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Federica Piras
- Department of Clinical Neuroscience and Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Fabrizio Piras
- Department of Clinical Neuroscience and Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Nerisa Banaj
- Department of Clinical Neuroscience and Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Felice Damato
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Gabriele Sani
- Department of Psychiatry, Department of Neuroscience, Head, Neck and Thorax, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Claudia Dacquino
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
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Melillo A, Caporusso E, Giordano GM, Giuliani L, Pezzella P, Perrottelli A, Bucci P, Mucci A, Galderisi S. Correlations between Negative Symptoms and Cognitive Deficits in Individuals at First Psychotic Episode or at High Risk of Psychosis: A Systematic Review. J Clin Med 2023; 12:7095. [PMID: 38002707 PMCID: PMC10672428 DOI: 10.3390/jcm12227095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/31/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
The present review aims to identify correlations between negative symptoms (NS) and deficits in neurocognition and social cognition in subjects with first-episode psychosis (FEP) and at-high-risk populations (HR). A systematic search of the literature published between 1 January 2005 and 31 December 2022 was conducted on PubMed, Scopus, and PsycInfo. Out of the 4599 records identified, a total of 32 studies met our inclusion/exclusion criteria. Data on a total of 3086 FEP and 1732 HR were collected. The available evidence shows that NS correlate with executive functioning and theory of mind deficits in FEP subjects, and with deficits in the processing speed, attention and vigilance, and working memory in HR subjects. Visual learning and memory do not correlate with NS in either FEP or HR subjects. More inconsistent findings were retrieved in relation to other cognitive domains in both samples. The available evidence is limited by sample and methodological heterogeneity across studies and was rated as poor or average quality for the majority of included studies in both FEP and CHR populations. Further research based on shared definitions of first-episode psychosis and at-risk states, as well as on more recent conceptualizations of negative symptoms and cognitive impairment, is highly needed.
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Affiliation(s)
| | | | - Giulia Maria Giordano
- Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie, 80138 Naples, Italy
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Marcó-García S, Guilera G, Ferrer-Quintero M, Ochoa S, Escuder-Romeva G, Martínez-Mondejar A, Montalbán-Roca V, Del Cacho N, Rubio-Abadal E, Escanilla-Casal A, Martínez-Zambrano F, Balsells-Mejía S, Huerta-Ramos E. The RECAPACITA project: Description of the clinical, neuropsychological and functional profile of a sample of people with severe mental disorder and legal capacity modification in Spain. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2023; 88:101874. [PMID: 36963181 DOI: 10.1016/j.ijlp.2023.101874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/28/2023] [Indexed: 06/01/2023]
Abstract
Severe mental disorder (SMD) includes people with long-term mental disorders, disability and social dysfunction. The mental capacity evaluation of the people has been a key aspect in legislative systems around the world and different proposals have been made. In countries like Spain, until 2021, the mental capacity of individuals was assessed by means of legal proceedings. In the last years, there has been a notable increase in the number of claims for legal incapacity, but no data are available on the total number of persons with CM, neither on the specific pathologies, or clinical and cognitive profiles. In view of the total absence of data on the profile of people with SMD and modification of capacity, the RECAPACITA study was born. This study includes patients with SMD and CM, as well as those without CM, with the aim to describe exhaustively their clinical, neuropsychological and functional profile of people with SMD and CM, as well as obtaining a basic description of the social environment. OBJECTIVES To describe CM in SMD, to identify clinical diagnoses, clinical severity and neuropsychological deterioration. METHODS Cross-sectional descriptive study. 77 adult patients with SMD and CM, inpatients from the mental health sector of the Parc Sanitari Sant Joan de Déu (Spain), outpatients linked to the community rehabilitation services (CRS), and penitentiary inmates. CM, sociodemographic, clinical, functional and neuropsychological data are collected. RESULTS In the sample, 59.5% present total CM. 74.7% are men (mean: 52.5 years). 87,0% have a diagnosis of schizophrenia. The estimated premorbid IQ is 91.4. The Global Assessment of Functioning (GAF) had a mean of 50.5, the "Clinical Global Impression Scale" (CGI) was 4.6 and Scale Unawareness of Mental Disorders (SUMD) was 9.28. The cognitive results shows a profile with slow proceeding speed (mean scale score: 6.6), good working memory (mean SC: 8.3) and adequate verbal comprehension (mean SC: 7.3). In memory, coding is altered (Pz: -1.9), and long-term spontaneous recall (Pz: -2.3). In abstract reasoning, a slight alteration is obtained (Mean SC: 6), as well as in semantic fluency (Mean SC: 6.3), phonological (Mean SC: 5.9), and inhibitory capacity (Mean SC: 5.7). CONCLUSIONS Most of the sample are men with schizophrenia, with a total MC assumed by a tutelary foundation. They show a moderate alteration in global functioning and clinical global impression, with partial awareness of the disease. They present dysexecutive mild cognitive impairment, with poor memory coding and free retrieval capacity, and a normal IQ, adequate verbal comprehension and working memory. This study is the first to present objective data on the psychiatric, functional and cognitive status of a group of patients with CM. Such research could be a good starting point to address a topic of great interest from the health, social and legal point of view of the CM processes of people with SMD.
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Affiliation(s)
- Silvia Marcó-García
- 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.
| | - Georgina Guilera
- Department of Social Psychology and Quantitative Psychology, Faculty of Psychology, University of Barcelona, 08035 Barcelona, Spain; Group of Invariance Studies for the Measurement and Analysis of Change in the Social and Health Environments (GEIMAC), Institute of Neurosciences (UBNeuro), University of Barcelona, 08035 Barcelona, Spain
| | - Marta Ferrer-Quintero
- 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; Biomedical Research in the Mental Health Network (CIBERSAM), Carlos III Health Institute, Madrid, Spain; Department of Social Psychology and Quantitative Psychology, Faculty of Psychology, University of Barcelona, 08035 Barcelona, Spain
| | - Susana Ochoa
- 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; Biomedical Research in the Mental Health Network (CIBERSAM), Carlos III Health Institute, Madrid, Spain
| | - Gemma Escuder-Romeva
- 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
| | | | | | - Núria Del Cacho
- 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
| | | | | | | | - Sol Balsells-Mejía
- Research Promotion and Management Department. Statistical Support, Hospital Sant Joan de Déu (HSJD), Barcelona, Spain
| | - Elena Huerta-Ramos
- 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; Biomedical Research in the Mental Health Network (CIBERSAM), Carlos III Health Institute, Madrid, Spain.
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Killey CM, Allott K, Whitson S, Francey SM, Bryant C, Simmons MB. Decisional capacity in young people with first episode psychosis, major depressive disorder and no mental disorder. Schizophr Res Cogn 2022; 28:100228. [PMID: 35242603 PMCID: PMC8861421 DOI: 10.1016/j.scog.2021.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/20/2021] [Accepted: 11/21/2021] [Indexed: 11/26/2022] Open
Abstract
We aimed to (1) examine decisional capacity for treatment in young people (aged 15 to 25 years) with first-episode psychosis (FEP), Major Depressive Disorder (MDD) and no mental disorder, and (2) determine which theoretically relevant factors are associated with, and predict decisional capacity. We assessed decisional capacity (using MacArthur Competence Assessment Tool-Treatment; MacCAT-T), cognitive abilities, insight and symptom severity in young people with no mental disorder (n = 38), MDD (n = 38) and FEP (n = 18) from inpatient and outpatient services. Most young people with MDD (84.2%) or no mental disorder (86.8%) had adequate decisional capacity to consent to treatment based on recommended cut-off scores, compared with fewer than half of the those with FEP (44.4%). Levels of capacity were not significantly different between young people with MDD and those with no mental disorder (p = .861). However, young people with FEP demonstrated significantly poorer decisional capacity than those with no mental disorder (p = .006) and MDD (p = .009). A hierarchical regression analysis suggested that differences may be better explained by variation in cognitive ability, especially thematic verbal recall. Greater symptom severity and poorer insight were associated with poorer decisional capacity for FEP (p = .008 and p < .001, respectively), but not MDD (p = .050 and p = .805, respectively). Cognitive performance (i.e., predicted IQ, processing speed, mental flexibility and thematic verbal memory) collectively explained 36.6% of the variance in decisional capacity (p < .001). Thematic verbal memory was the strongest predictor of decisional capacity (p < .001). Supports for memory should be implemented to facilitate involvement in treatment decisions during the early course of illness. We tested decisional capacity in young people with first episode psychosis, major depressive disorder and no mental disorder. Most with major depressive disorder or no mental disorder had adequate capacity, compared to fewer than half with first episode psychosis. In first episode psychosis, greater symptom severity and poorer insight were related to poorer decisional capacity. Cognitive performance significantly explained variance in decisional capacity. A subgroup of young people will need support to be involved in making decisions, even in early stages of illness.
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Harris JI, Hanson D, Leskela J, Billig J, Padilla-Martinez V, Boyd J, Nienow T. Reconsidering research exclusion for serious mental illness: Ethical principles, current status, and recommendations. J Psychiatr Res 2021; 143:138-143. [PMID: 34487990 DOI: 10.1016/j.jpsychires.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/19/2021] [Accepted: 09/01/2021] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- J Irene Harris
- VA Bedford Healthcare System, Bedford, MA, USA; University of Minnesota, Minneapolis, MN, USA.
| | | | - Jennie Leskela
- University of Minnesota, Minneapolis, MN, USA; ABPP Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - John Billig
- ABPP, National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA
| | | | - Jennifer Boyd
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California San Francisco, San Francisco, CA, USA
| | - Tasha Nienow
- Minneapolis VA Health Care System, Minneapolis, MN, USA
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Vanova M, Aldridge-Waddon L, Jennings B, Puzzo I, Kumari V. Reading skills deficits in people with mental illness: A systematic review and meta-analysis. Eur Psychiatry 2020; 64:e19. [PMID: 33138882 PMCID: PMC8057468 DOI: 10.1192/j.eurpsy.2020.98] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Good reading skills are important for appropriate functioning in everyday life, scholastic performance, and acquiring a higher socioeconomic status. We conducted the first systematic review and meta-analysis to quantify possible deficits in specific reading skills in people with a variety of mental illnesses, including personality disorders (PDs). METHODS We performed a systematic search of multiple databases from inception until February 2020 and conducted random-effects meta-analyses. RESULTS The search yielded 34 studies with standardized assessments of reading skills in people with one or more mental illnesses. Of these, 19 studies provided data for the meta-analysis. Most studies (k = 27; meta-analysis, k = 17) were in people with schizophrenia and revealed large deficits in phonological processing (Hedge's g = -0.88, p < 0.00001), comprehension (Hedge's g = -0.96, p < 0.00001) and reading rate (Hedge's g = -1.22, p = 0.002), relative to healthy controls; the single-word reading was less affected (Hedge's g = -0.70, p < 0.00001). A few studies in affective disorders and nonforensic PDs suggested weaker deficits (for all, Hedge's g < -0.60). In forensic populations with PDs, there was evidence of marked phonological processing (Hedge's g = -0.85, p < 0.0001) and comprehension deficits (Hedge's g = -0.95, p = 0.0003). CONCLUSIONS People with schizophrenia, and possibly forensic PD populations, demonstrate a range of reading skills deficits. Future studies are needed to establish how these deficits directly compare to those seen in developmental or acquired dyslexia and to explore the potential of dyslexia interventions to improve reading skills in these populations.
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Affiliation(s)
- Martina Vanova
- Centre for Cognitive Neuroscience, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom.,Division of Psychology, Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
| | - Luke Aldridge-Waddon
- Centre for Cognitive Neuroscience, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom.,Division of Psychology, Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
| | - Ben Jennings
- Centre for Cognitive Neuroscience, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom.,Division of Psychology, Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
| | - Ignazio Puzzo
- Centre for Cognitive Neuroscience, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom.,Division of Psychology, Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
| | - Veena Kumari
- Centre for Cognitive Neuroscience, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom.,Division of Psychology, Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
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Parmigiani G, Mandarelli G, Meynen G, Carabellese F, Ferracuti S. Translating clinical findings to the legal norm: the Defendant's Insanity Assessment Support Scale (DIASS). Transl Psychiatry 2019; 9:278. [PMID: 31699969 PMCID: PMC6838307 DOI: 10.1038/s41398-019-0628-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 09/24/2019] [Accepted: 10/20/2019] [Indexed: 11/09/2022] Open
Abstract
Insanity definition and the threshold for satisfying its legal criteria tend to vary depending on the jurisdictions. Yet, in Western countries, the legal standards for insanity often rely on the presence of cognitive and/or volitional impairment of the defendant at crime time. Despite some efforts having been made to guide and structure criminal responsibility evaluations, a valid instrument that could be useful to guide forensic psychiatrists' criminal responsibility assessments in different jurisdictions is lacking. This is a gap that needs to be addressed, considering the significant forensic and procedural implications of psychiatric evaluations. In addition, differences in methodology used in insanity assessments may also have consequences for the principle of equal rights for all citizens before the law, which should be guaranteed in the European Union. We developed an instrument, the Defendant's Insanity Assessment Support Scale (DIASS), which can be useful to support, structure, and guide the insanity assessment across different jurisdictions, in order to improve reliability and consistency of such evaluations.
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Affiliation(s)
- Giovanna Parmigiani
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy.
| | - Gabriele Mandarelli
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
- Section of Criminology and Forensic Psychiatry, University of Bari Aldo Moro, Department of Interdisciplinary Medicine, Bari, Italy
| | - Gerben Meynen
- Willem Pompe Institute for Criminal Law and Criminology, Utrecht University, Utrecht, The Netherlands
- Faculty of Humanities, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Felice Carabellese
- Section of Criminology and Forensic Psychiatry, University of Bari Aldo Moro, Department of Interdisciplinary Medicine, Bari, Italy
| | - Stefano Ferracuti
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
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Mandarelli G, Parmigiani G, Carabellese F, Codella S, Roma P, Brancadoro D, Ferretti A, Alessandro L, Pinto G, Ferracuti S. Decisional capacity to consent to treatment and anaesthesia in patients over the age of 60 undergoing major orthopaedic surgery. MEDICINE, SCIENCE, AND THE LAW 2019; 59:247-254. [PMID: 31366276 DOI: 10.1177/0025802419865854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
| | | | - Felice Carabellese
- Section of Criminology and Forensic Psychiatry, Department of Interdisciplinary Medicine, University of Bari, Italy
| | - Silvia Codella
- Anesthesiology Department, Sant'Andrea Hospital, 'Sapienza' University of Rome, Italy
| | - Paolo Roma
- Department of Human Neurosciences, 'Sapienza' University of Rome, Italy
| | - Domitilla Brancadoro
- Anesthesiology Department, Sant'Andrea Hospital, 'Sapienza' University of Rome, Italy
| | - Andrea Ferretti
- Orthopaedic Unit, Sant'Andrea Hospital, 'Sapienza' University of Rome, Italy
| | | | - Giovanni Pinto
- Anesthesiology Department, Sant'Andrea Hospital, 'Sapienza' University of Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neurosciences, 'Sapienza' University of Rome, Italy
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Sugawara N, Yasui-Furukori N, Sumiyoshi T. Competence to Consent and Its Relationship With Cognitive Function in Patients With Schizophrenia. Front Psychiatry 2019; 10:195. [PMID: 31031653 PMCID: PMC6474312 DOI: 10.3389/fpsyt.2019.00195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/18/2019] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Norio Sugawara
- Department of Clinical Epidemiology, Translational Medical Center, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Norio Yasui-Furukori
- Department of Neuropsychiatry, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Tomiki Sumiyoshi
- Department of Clinical Epidemiology, Translational Medical Center, National Center of Neurology and Psychiatry, Kodaira, Japan
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Treatment decision-making capacity in non-consensual psychiatric treatment: a multicentre study. Epidemiol Psychiatr Sci 2018; 27:492-499. [PMID: 28274298 PMCID: PMC6999012 DOI: 10.1017/s2045796017000063] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AIMS To evaluate treatment decision-making capacity (DMC) to consent to psychiatric treatment in involuntarily committed patients and to further investigate possible associations with clinical and socio-demographic characteristics of patients. METHODS 131 involuntarily hospitalised patients were recruited in three university hospitals. Mental capacity to consent to treatment was measured with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T); psychiatric symptoms severity (Brief Psychiatric Rating Scale, BPRS-E) and cognitive functioning (Mini Mental State Examination, MMSE) were also assessed. RESULTS Mental capacity ratings for the 131 involuntarily hospitalised patients showed that patients affected by bipolar disorders (BD) scored generally better than those affected by schizophrenia spectrum disorders (SSD) in MacCAT-T appreciation (p < 0.05) and reasoning (p < 0.01). Positive symptoms were associated with poorer capacity to appreciate (r = -0.24; p < 0.01) and reason (r = -0.27; p < 0.01) about one's own treatment. Negative symptoms were associated with poorer understanding of treatment (r = -0.23; p < 0.01). Poorer cognitive functioning, as measured by MMSE, negatively affected MacCAT-T understanding in patients affected by SSD, but not in those affected by BD (SSD r = 0.37; p < 0.01; BD r = -0.01; p = 0.9). Poorer MacCAT-T reasoning was associated with more manic symptoms in the BD group of patients but not in the SSD group (BD r = -0.32; p < 0.05; SSD r = 0.03; p = 0.8). Twenty-two per cent (n = 29) of the 131 recruited patients showed high treatment DMC as defined by having scored higher than 75% of understanding, appreciating and reasoning MacCAT-T subscales maximum sores and 2 at expressing a choice. The remaining involuntarily hospitalised patients where considered to have low treatment DMC. Chi-squared disclosed that 32% of BD patients had high treatment DMC compared with 9% of SSD patients (p < 0.001). CONCLUSIONS Treatment DMC can be routinely assessed in non-consensual psychiatric settings by the MacCAT-T, as is the case of other clinical variables. Such approach can lead to the identification of patients with high treatment DMC, thus drawing attention to possible dichotomy between legal and clinical status.
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Roberts L, Kim JP. Does informed consent given by healthy individuals when enrolling in clinical research feel less voluntary than for ill individuals? J Psychiatr Res 2018; 103:33-37. [PMID: 29772484 DOI: 10.1016/j.jpsychires.2018.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/17/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Laura Roberts
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA, USA, 94305-5717
| | - Jane Paik Kim
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA, USA, 94305-5717.
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Spencer BWJ, Gergel T, Hotopf M, Owen GS. Unwell in hospital but not incapable: cross-sectional study on the dissociation of decision-making capacity for treatment and research in in-patients with schizophrenia and related psychoses. Br J Psychiatry 2018; 213:484-489. [PMID: 29909778 PMCID: PMC6054873 DOI: 10.1192/bjp.2018.85] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 03/09/2018] [Accepted: 03/25/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Consent to research with decision-making capacity for research (DMC-R) is normally a requirement for study participation. Although the symptoms of schizophrenia and related psychoses are known to affect decision-making capacity for treatment (DMC-T), we know little about their effect on DMC-R.AimsWe aimed to determine if DMC-R differs from DMC-T in proportion and associated symptoms in an in-patient sample of people with schizophrenia and related psychoses. METHOD Cross-sectional study of psychiatric in-patients admitted for assessment and/or treatment of schizophrenia and related psychoses. We measured DMC-R and DMC-T using 'expert judgement' clinical assessment guided by the MacArthur Competence Assessment Tool for Clinical Research, the MacArthur Competence Assessment Tool for Treatment and the legal framework of the Mental Capacity Act (2005), in addition to symptoms of psychosis. RESULTS There were 84 participants in the study. Half the participants had DMC-R (51%, 95% CI 40-62%) and a third had DMC-T (31%, 95% CI 21-43%) and this difference was statistically significant (P < 0.01). Thought disorder was most associated with lacking DMC-R (odds ratio 5.72, 95% CI 2.01-16.31, P = 0.001), whereas lack of insight was most associated with lacking DMC-T (odds ratio 26.34, 95% CI 3.60-192.66, P = 0.001). With the exception of improved education status and better DMC-R, there was no effect of sociodemographic variables on either DMC-R or DMC-T. CONCLUSIONS We have shown that even when severely unwell, people with schizophrenia and related psychoses in in-patient settings commonly retain DMC-R despite lacking DMC-T. Furthermore, different symptoms have different effects on decision-making abilities for different decisions. We should not view in-patient psychiatric settings as a research 'no-go area' and, where appropriate, should recruit in these settings.Declaration of interestNone.
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Affiliation(s)
- Benjamin Walter Jack Spencer
- Mental Health, Ethics and Law Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley National Health Service Foundation Trust, Maudsley Hospital, UK
| | - Tania Gergel
- Mental Health, Ethics and Law Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Matthew Hotopf
- Mental Health, Ethics and Law Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley National Health Service Foundation Trust, Maudsley Hospital, UK
| | - Gareth S. Owen
- Mental Health, Ethics and Law Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley National Health Service Foundation Trust, Maudsley Hospital, UK
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Mandarelli G, Moretti G, Pasquini M, Nicolò G, Ferracuti S. Informed Consent Decision-Making in Deep Brain Stimulation. Brain Sci 2018; 8:E84. [PMID: 29751598 PMCID: PMC5977075 DOI: 10.3390/brainsci8050084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/20/2022] Open
Abstract
Deep brain stimulation (DBS) has proved useful for several movement disorders (Parkinson’s disease, essential tremor, dystonia), in which first and/or second line pharmacological treatments were inefficacious. Initial evidence of DBS efficacy exists for refractory obsessive-compulsive disorder, treatment-resistant major depressive disorder, and impulse control disorders. Ethical concerns have been raised about the use of an invasive surgical approach involving the central nervous system in patients with possible impairment in cognitive functioning and decision-making capacity. Most of the disorders in which DBS has been used might present with alterations in memory, attention, and executive functioning, which may have an impact on the mental capacity to give informed consent to neurosurgery. Depression, anxiety, and compulsivity are also common in DBS candidate disorders, and could also be associated with an impaired capacity to consent to treatment or clinical research. Despite these issues, there is limited empirical knowledge on the decision-making levels of these patients. The possible informed consent issues of DBS will be discussed by focusing on the specific treatable diseases.
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Affiliation(s)
- Gabriele Mandarelli
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Germana Moretti
- Department of Mental Health, ASL Roma 5, 00034 Colleferro, Italy.
| | - Massimo Pasquini
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Giuseppe Nicolò
- Department of Mental Health, ASL Roma 5, 00034 Colleferro, Italy.
| | - Stefano Ferracuti
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
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Abstract
OBJECTIVE Making decisions is central to the exercise of control over one's well-being. Many individuals with serious mental illness (SMI) experience limitations in their decision-making capacity. These individuals have often been placed under legal guardianship and substitute decision makers have been appointed to make decisions on their behalf. More recently, supported decision making (SDM) has emerged as a possible alternative in some cases. SDM involves recruitment of trusted supports to enhance an individual's capacity in the decision-making process, enabling him or her to retain autonomy in life decisions. This overview examines issues associated with decision-making capacity in SMI, frameworks of substitute decision making and SDM, and emerging empirical research on SDM. METHOD This is an overview of the medical and legal literature on decision making capacity and supported decision making for persons with SMI. RESULTS Many but not all individuals with SMI exhibit decrements in decision-making capacity and skill, in part due to cognitive impairment. There are no published data on rates of substitute decision making/guardianship or SDM for SMI. Only three empirical studies have explored SDM in this population. These studies suggest that SDM is viewed as an acceptable and potentially superior alternative to substitute decision making for patients and their caretakers. CONCLUSIONS SDM is a promising alternative to substitute decision making for persons with SMI. Further empirical research is needed to clarify candidates for SDM, decisions in need of support, selection of supporters, guidelines for the SDM process, integration of SDM with emerging technological platforms, and outcomes of SDM. Recommendations for implementation of and research on SDM for SMI are provided.
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Affiliation(s)
- Dilip V. Jeste
- Department of Psychiatry, University of California, San Diego, La Jolla, CA USA
- Sam and Rose Stein Institute for Research on Aging, University of California, San Diego, La Jolla, CA USA
| | - Graham M.L. Eglit
- Department of Psychiatry, University of California, San Diego, La Jolla, CA USA
- Sam and Rose Stein Institute for Research on Aging, University of California, San Diego, La Jolla, CA USA
| | - Barton W. Palmer
- Department of Psychiatry, University of California, San Diego, La Jolla, CA USA
- Sam and Rose Stein Institute for Research on Aging, University of California, San Diego, La Jolla, CA USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA USA
| | | | - Peter Blanck
- Burton Blatt Institute, Syracuse University, Syracuse, NY USA
| | - Elyn R. Saks
- Gould School of Law, Saks Institute for Mental Health Law, Policy, and Ethics, University of Southern California, Los Angeles, CA
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Tampi RR, Young J, Balachandran S, Dasarathy D, Tampi D. Ethical, Legal and Forensic Issues in Geriatric Psychiatry. Curr Psychiatry Rep 2018; 20:1. [PMID: 29368239 DOI: 10.1007/s11920-018-0865-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF THE REVIEW To evaluate the ethical, legal and forensic issues that is faced by the older adult population. RECENT FINDINGS Many older individuals will face a host of ethical, medical and legal issues associated with their care. Most prominent among these issues are the maintenance of autonomy while ensuring their safety and the safety of individuals who care for them. Decisions regarding end of life including the formulation of advance directives add to the complexity of care for these older adults. A significant portion of individuals in the criminal justice system are aging and many of these individuals have psychiatric disorders. Their care is compromised due to the lack of appropriate services within criminal justice system for providing care for these individuals. CONCLUSIONS Ethical, legal and forensic issues among older are not uncommon and complicate the care of these vulnerable individuals.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry, MetroHealth, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA. .,Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Juan Young
- Department of Psychiatry, MetroHealth, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Silpa Balachandran
- Department of Psychiatry, MetroHealth, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Hostiuc S, Rusu MC, Negoi I, Drima E. Testing decision-making competency of schizophrenia participants in clinical trials. A meta-analysis and meta-regression. BMC Psychiatry 2018; 18:2. [PMID: 29304845 PMCID: PMC5756338 DOI: 10.1186/s12888-017-1580-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 12/14/2017] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Sorin Hostiuc
- Carol Davila University of Medicine and Pharmacy, Sos.Vitan Barzesti 9, 042122 Sector 4, Bucuresti, Romania. .,National Institute of Legal Medicine, Bucharest, Romania.
| | - Mugurel Constantin Rusu
- 0000 0000 9828 7548grid.8194.4Carol Davila University of Medicine and Pharmacy, Sos.Vitan Barzesti 9, 042122 Sector 4, Bucuresti, Romania
| | - Ionut Negoi
- 0000 0000 9828 7548grid.8194.4Carol Davila University of Medicine and Pharmacy, Sos.Vitan Barzesti 9, 042122 Sector 4, Bucuresti, Romania
| | - Eduard Drima
- 0000 0004 0571 5814grid.411040.0University of Medicine and Pharmacy, Galați, Romania
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Bourgeois JA, Cohen MA, Erickson JM, Brendel RW. Decisional and Dispositional Capacity Determinations: Neuropsychiatric Illness and an Integrated Clinical Paradigm. PSYCHOSOMATICS 2017; 58:565-573. [DOI: 10.1016/j.psym.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/07/2017] [Accepted: 07/09/2017] [Indexed: 10/19/2022]
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Pousa E, Ochoa S, Cobo J, Nieto L, Usall J, Gonzalez B, Garcia-Ribera C, Pérez Solà V, Ruiz AI, Baños I, Cobo J, García-Ribera C, González B, Massons C, Nieto L, Monserrat C, Ochoa S, Pousa E, Ruiz AI, Ruiz I, Sanchez-Cabezudo D, Usall J. A deeper view of insight in schizophrenia: Insight dimensions, unawareness and misattribution of particular symptoms and its relation with psychopathological factors. Schizophr Res 2017; 189:61-68. [PMID: 28237605 DOI: 10.1016/j.schres.2017.02.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/08/2017] [Accepted: 02/11/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE 1. To describe insight in a large sample of schizophrenia subjects from a multidimensional point of view, including unawareness of general insight dimensions as well as unawareness and misattribution of particular symptoms. 2. To explore the relationship between unawareness and clinical and socio-demographic variables. METHODS 248 schizophrenia patients were assessed with the Positive and Negative Syndrome Scale (PANSS, five factor model of Lindenmayer) and the full Scale of Unawareness of Mental Disorder (SUMD). Bivariate associations and multiple linear regression analyses were used to investigate the relationship between unawareness, symptoms and socio-demographic variables. RESULTS Around 40% of the sample showed unawareness of mental disorder, of the need for medication and of the social consequences. Levels of unawareness and misattribution of particular symptoms varied considerably. General unawareness dimensions showed small significant correlations with positive, cognitive and excitement factors of psychopathology, whereas these symptom factors showed higher correlations with unawareness of particular symptoms. Similarly, regression models showed a small significant predictive value of positive symptoms in the three general unawareness dimensions while a moderate one in the prediction of particular symptoms. Misattribution showed no significant correlations with any symptom factors. CONCLUSIONS Results confirm that insight in schizophrenia is a multi-phased phenomenon and that unawareness into particular symptoms varies widely. The overlap between unawareness dimensions and psychopathology is small and seems to be restricted to positive and cognitive symptoms, supporting the accounts from cognitive neurosciences that suggest that besides basic cognition poor insight may be in part a failure of self-reflection or strategic metacognition.
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Affiliation(s)
- Esther Pousa
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Salut Mental. Parc Taulí Sabadell, Hospital Universitari - UAB Universitat Autònoma de Barcelona, CIBERSAM, Campus d'Excel.lència Internacional. 08208 Sabadell, Barcelona, Spain.
| | - Susana Ochoa
- Research and Development Unit, Parc Sanitari San Joan de Dèu - CIBERSAM Sant Boi de Llobregat, Barcelona, Spain
| | - Jesús Cobo
- Salut Mental. Parc Taulí Sabadell, Hospital Universitari - UAB Universitat Autònoma de Barcelona, CIBERSAM, Campus d'Excel.lència Internacional. 08208 Sabadell, Barcelona, Spain; Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona, Spain
| | - Lourdes Nieto
- Department of Research; Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz.Calzada México-Xochimilco 101. 14370 San Lorenzo Huipulco - Tlalpan, México D. F. México
| | - Judith Usall
- Research and Development Unit, Parc Sanitari San Joan de Dèu - CIBERSAM Sant Boi de Llobregat, Barcelona, Spain
| | - Beatriz Gonzalez
- Research and Development Unit, Parc Sanitari San Joan de Dèu - CIBERSAM Sant Boi de Llobregat, Barcelona, Spain
| | - Carles Garcia-Ribera
- Servicio de Psiquiatría del Hospital de la Santa Creu i Sant Pau Barcelona, IIB-Sant Pau, Sant Quintí 89, 08025 Barcelona, Spain
| | - Victor Pérez Solà
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona, Spain; Servicio de Psiquiatría del Hospital de la Santa Creu i Sant Pau Barcelona, IIB-Sant Pau, Sant Quintí 89, 08025 Barcelona, Spain; Centro de Investigación Biomédica En Red de Salud Mental, CIBERSAM, Spain
| | - Ada-I Ruiz
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | | | - Iris Baños
- Research and Development Unit, Parc Sanitari San Joan de Dèu - CIBERSAM Sant Boi de Llobregat, Barcelona, Spain
| | - Jesús Cobo
- Salut Mental. Parc Taulí Sabadell, Hospital Universitari - UAB Universitat Autònoma de Barcelona, CIBERSAM, Campus d'Excel.lència Internacional. 08208 Sabadell, Barcelona, Spain; Salut Mental. Parc Taulí Sabadell, Hospital Universitari - UAB Universitat Autònoma de Barcelona, CIBERSAM, Campus d'Excel.lència Internacional. 08208 Sabadell, Barcelona, Spain
| | - Carles García-Ribera
- Servicio de Psiquiatría del Hospital de la Santa Creu i Sant Pau Barcelona, IIB-Sant Pau, Sant Quintí 89, 08025 Barcelona, Spain
| | - Beatriz González
- Mental Health Department, Hospital Benito Menni, Sant Boi de Llobregat, Barcelona, Spain
| | - Carmina Massons
- Salut Mental. Parc Taulí Sabadell, Hospital Universitari - UAB Universitat Autònoma de Barcelona, CIBERSAM, Campus d'Excel.lència Internacional. 08208 Sabadell, Barcelona, Spain
| | - Lourdes Nieto
- Department of Research; Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz.Calzada México-Xochimilco 101. 14370 San Lorenzo Huipulco - Tlalpan, México D. F. México
| | - Clara Monserrat
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain
| | - Susana Ochoa
- Research and Development Unit, Parc Sanitari San Joan de Dèu - CIBERSAM Sant Boi de Llobregat, Barcelona, Spain
| | - Esther Pousa
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Salut Mental. Parc Taulí Sabadell, Hospital Universitari - UAB Universitat Autònoma de Barcelona, CIBERSAM, Campus d'Excel.lència Internacional. 08208 Sabadell, Barcelona, Spain
| | - Ada-Inmaculada Ruiz
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Isabel Ruiz
- Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona, Spain
| | | | - Judith Usall
- Research and Development Unit, Parc Sanitari San Joan de Dèu - CIBERSAM Sant Boi de Llobregat, Barcelona, Spain
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Spencer BWJ, Shields G, Gergel T, Hotopf M, Owen GS. Diversity or disarray? A systematic review of decision-making capacity for treatment and research in schizophrenia and other non-affective psychoses. Psychol Med 2017; 47:1906-1922. [PMID: 28441976 DOI: 10.1017/s0033291717000502] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- B W J Spencer
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - G Shields
- South London and Maudsley NHS Foundation Trust,Maudsley Hospital,Denmark Hill,London, SE5 8AZ,UK
| | - T Gergel
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - M Hotopf
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - G S Owen
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
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Mukherjee A, Livinski AA, Millum J, Chamut S, Boroumand S, Iafolla TJ, Adesanya MR, Dye BA. Informed consent in dental care and research for the older adult population: A systematic review. J Am Dent Assoc 2017; 148:211-220. [PMID: 28065430 DOI: 10.1016/j.adaj.2016.11.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/19/2016] [Accepted: 11/28/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ethics in health care and research is based on the fundamental principle of informed consent. However, informed consent in geriatric dentistry is not well documented. Poor health, cognitive decline, and the passive nature of many geriatric patients complicate this issue. METHODS The authors completed this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors searched the PubMed (MEDLINE), Web of Science, PsycINFO, and Cochrane Library databases. The authors included studies if they involved participants 65 years or older and discussed topics related to informed consent beyond obtaining consent for health care. The authors explored informed consent issues in dentistry and other biomedical care and research. RESULTS The authors included 80 full-text articles on the basis of the inclusion criteria. Of these studies, 33 were conducted in the United States, 29 addressed consent issues in patients with cognitive impairment, 29 were conducted in patients with medical conditions, and only 3 involved consent related to dental care or research. CONCLUSIONS Informed consent is a neglected topic in geriatric dental care and research. Substantial knowledge gaps exist between the understanding and implementation of consent procedures. Additional research in this area could help address contemporary consent issues typically encountered by dental practitioners and to increase active participation from the geriatric population in dental care and research. PRACTICAL IMPLICATIONS This review is the first attempt, to the authors' knowledge, to identify informed consent issues comprehensively in geriatric dentistry. There is limited information in the informed consent literature covering key concepts applicable to geriatric dentistry. Addressing these gaps could assist dental health care professionals in managing complex ethical issues associated with geriatric dental patients.
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Palmer BW, Harmell AL. Assessment of Healthcare Decision-making Capacity. Arch Clin Neuropsychol 2016; 31:530-40. [PMID: 27551024 DOI: 10.1093/arclin/acw051] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 11/13/2022] Open
Abstract
It is often necessary for neuropsychologists, clinical psychologists, and other healthcare professionals to assess an individual's capacity to consent to treatment related to healthcare. This task can be challenging and requires a delicate balance of both respect for individuals' autonomy, as well as the protection of individuals with diminished capacity to make an autonomous decision. The purpose of the present review is to provide an overview of the conceptual model of decisional capacity as well as a brief summary of some of the currently available instruments designed to help evaluate medical decision making. In addition, current empirical literature on the relationship between neuropsychological abilities and decision-making capacity is discussed and a brief set of recommendations is provided to further aid clinicians or consultants when they are required to complete the ethically important but difficult task of making determinations about healthcare decision-making capacity.
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Affiliation(s)
- Barton W Palmer
- Department of Psychiatry, University of California, San Diego, CA, USA Veterans Medical Research Foundation, San Diego, CA, USA Veterans Affairs San Diego Healthcare System, San Diego, CA, USA Center for Healthy Aging/Stein Institute for Research on Aging, University of California, San Diego, CA, USA
| | - Alexandrea L Harmell
- Department of Psychiatry, University of California, San Diego, CA, USA Center for Healthy Aging/Stein Institute for Research on Aging, University of California, San Diego, CA, USA San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology , San Diego, CA, USA
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Psychopathology, psychopharmacological properties, decision-making capacity to consent to clinical research and the willingness to participate among long-term hospitalized patients with schizophrenia. Psychiatry Res 2016; 237:323-30. [PMID: 26847945 DOI: 10.1016/j.psychres.2016.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 11/18/2015] [Accepted: 01/11/2016] [Indexed: 11/22/2022]
Abstract
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.
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Parmigiani G, Mandarelli G, Dacquino C, Pompili P, Lelli Chiesa G, Ferracuti S. Decisional Capacity to Consent to Clinical Research Involving Placebo in Psychiatric Patients. J Forensic Sci 2015; 61:388-393. [DOI: 10.1111/1556-4029.13000] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/15/2015] [Accepted: 05/24/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Giovanna Parmigiani
- Department of Neurology and Psychiatry; University of Rome “Sapienza”; viale dell'Universitá 30 00185 Rome Italy
| | - Gabriele Mandarelli
- Department of Neurology and Psychiatry; University of Rome “Sapienza”; viale dell'Universitá 30 00185 Rome Italy
| | - Claudia Dacquino
- Department of Anatomical, Histological Forensic and Orthopaedic Sciences; University of Rome “Sapienza”; viale Regina Elena 336 00185 Rome Italy
| | - Pieritalo Pompili
- Department of Neurosciences, Mental Health and Sensory Organs; University of Rome “Sapienza”; via di Grotta Rossa 1035 00189 Rome Italy
| | - Giovanni Lelli Chiesa
- Department of Neurosciences, Mental Health and Sensory Organs; University of Rome “Sapienza”; via di Grotta Rossa 1035 00189 Rome Italy
| | - Stefano Ferracuti
- Department of Neurology and Psychiatry; University of Rome “Sapienza”; viale dell'Universitá 30 00185 Rome Italy
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Ramos Pozón S. Bioethical procedure for decision-making in mental health. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2015; 9:230. [PMID: 26600194 DOI: 10.1016/j.rpsm.2015.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
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Frost KH, Lincoln SH, Norkett EM, Jin MX, Gonzalez-Heydrich J, D’Angelo EJ. The Ethical Inclusion of Children With Psychotic Disorders in Research: Recommendations for an Educative, Multimodal Assent Process. ETHICS & BEHAVIOR 2015. [DOI: 10.1080/10508422.2015.1063425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ryan C, Callaghan S, Peisah C. The capacity to refuse psychiatric treatment: a guide to the law for clinicians and tribunal members. Aust N Z J Psychiatry 2015; 49:324-33. [PMID: 25690742 DOI: 10.1177/0004867415572007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In some Australian states clinicians and mental health tribunal members are already required to assess a person's decision-making capacity before involuntary treatment can be applied. Professionals in other jurisdictions will likely soon be required to do the same as mental health law reform in most Australian jurisdictions makes the assessment of decision-making capacity a central component of the process of providing unconsented psychiatric treatment. We provide a guide to the legal issues around the capacity to refuse psychiatric treatment to assist with this task. METHOD We review the legislation in the four Australian states most advanced in the mental health law reform process and use examples from clinical practice and the common law to describe how decision-making capacity should be assessed by these statutory standards. RESULTS Clinicians and tribunal members will primarily be required to judge whether a person with mental illness can understand the information relevant to the treatment decision and whether he or she can use or weigh that information to come to a decision. A person with a mental illness is presumed to have capacity, but that presumption can be rebutted. Capacity is specific to the decision at hand and cannot be determined by the nature of the decision made. CONCLUSIONS The information provided should assist clinicians and tribunal members to make determinations of decision-making capacity around treatment refusal in the context of mental illness.
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Affiliation(s)
- Christopher Ryan
- The Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia Centre for Values, Ethics and the Law in Medicine, University of Sydney
| | - Sascha Callaghan
- Centre for Values, Ethics and the Law in Medicine, University of Sydney Sydney Law School, University of Sydney, Sydney, Australia
| | - Carmelle Peisah
- The Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia Capacity Australia, Crows Nest, Australia School of Psychiatry, Faculty of Medicine, University of New South Wales, Australia
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Belvederi Murri M, Respino M, Innamorati M, Cervetti A, Calcagno P, Pompili M, Lamis DA, Ghio L, Amore M. Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis. Schizophr Res 2015; 162:234-47. [PMID: 25631453 DOI: 10.1016/j.schres.2015.01.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 12/23/2014] [Accepted: 01/02/2015] [Indexed: 12/22/2022]
Abstract
Among patients with schizophrenia, better insight may be associated with depression, but the findings on this issue are mixed. We examined the association between insight and depression in schizophrenia by conducting a systematic review and meta-analysis. The meta-analysis was based on 59 correlational studies and showed that global clinical insight was associated weakly, but significantly with depression (effect size r=0.14), as were the insight into the mental disorder (r=0.14), insight into symptoms (r=0.14), and symptoms' attributions (r=0.17). Conversely, neither insight into the social consequences of the disorder nor into the need for treatment was associated with symptoms of depression. Better cognitive insight was significantly associated with higher levels of depression. The exploratory meta-regression showed that methodological factors (e.g. the instrument used to assess depression and the phase of the illness) can significantly influence the magnitude of the association between insight and depression. Moreover, results from longitudinal studies suggest that the relation between insight and depression might be stronger than what is observed at the cross-sectional level. Finally, internalized stigma, illness perception, recovery attitudes, ruminative style, and premorbid adjustment seem to be relevant moderators and/or mediators of the association between insight and depression. In conclusion, literature indicates that among patients with schizophrenia, better insight is associated with higher levels of depressive symptoms. Thus, interventions aimed at promoting patients' insight should take into account the clinical implications of these findings.
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Affiliation(s)
- Martino Belvederi Murri
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy; Institute of Psychiatry, Department of Psychological Medicine, King's College London, London, UK.
| | - Matteo Respino
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Marco Innamorati
- Department of Human Sciences, European University of Rome, Italy
| | - Alice Cervetti
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Pietro Calcagno
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - Dorian A Lamis
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Lucio Ghio
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
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Kontos N, Querques J, Freudenreich O. Capable of more: some underemphasized aspects of capacity assessment. PSYCHOSOMATICS 2014; 56:217-26. [PMID: 25648077 DOI: 10.1016/j.psym.2014.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/13/2014] [Accepted: 11/17/2014] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Nicholas Kontos
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA..
| | - John Querques
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Mandarelli G, Tarsitani L, Parmigiani G, Polselli GM, Frati P, Biondi M, Ferracuti S. Mental Capacity in Patients Involuntarily or Voluntarily Receiving Psychiatric Treatment for an Acute Mental Disorder. J Forensic Sci 2014; 59:1002-7. [DOI: 10.1111/1556-4029.12420] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Revised: 05/01/2013] [Accepted: 05/10/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Gabriele Mandarelli
- Department of Neurosciences; Mental Health and Sensory Organs; University of Rome “Sapienza”; via di Grottarossa 1035, 00189 Rome Italy
| | - Lorenzo Tarsitani
- Department of Neurology and Psychiatry; University of Rome “Sapienza”; Viale dell'Università 30 00185 Rome Italy
| | - Giovanna Parmigiani
- Department of Neurology and Psychiatry; University of Rome “Sapienza”; Viale dell'Università 30 00185 Rome Italy
| | - Gian M. Polselli
- Department of Neurology and Psychiatry; University of Rome “Sapienza”; Viale dell'Università 30 00185 Rome Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences; University of Rome “Sapienza”; Viale Regina Elena 336 00185 Rome Italy
| | - Massimo Biondi
- Department of Neurology and Psychiatry; University of Rome “Sapienza”; Viale dell'Università 30 00185 Rome Italy
| | - Stefano Ferracuti
- Department of Neurosciences; Mental Health and Sensory Organs; University of Rome “Sapienza”; via di Grottarossa 1035, 00189 Rome Italy
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Validation of Chinese version of the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) in patients with schizophrenia spectrum disorders. Psychiatry Res 2013; 210:634-40. [PMID: 23928212 DOI: 10.1016/j.psychres.2013.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 06/03/2013] [Accepted: 07/04/2013] [Indexed: 11/21/2022]
Abstract
There is a lack of validated instruments assessing the decision-making capacity to consent to clinical research of patients with schizophrenia spectrum disorders who speak Chinese. This study aimed to determine the validity and reliability of the Chinese version of MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). The MacCAT-CR using a hypothetical study, the Positive and Negative Syndrome Scale (PANSS), the Mini-Mental State Examination (MMSE) assessed 139 patients with schizophrenia or schizoaffective disorder. The Cronbach's alpha coefficient was 0.74. The intra-class coefficients for understanding, appreciation, and reasoning scores ranged from 0.53 to 0.81. Regarding validity, the understanding, appreciation and reasoning scores were negatively correlated with the PANSS (r ranged from -0.27 to -0.33), and the negative subscale score (r ranged from -0.31 to -0.37) as well as positively correlated with the MMSE (r ranged from 0.26 to 0.43). All pvalues were less than 0.01. The factor analysis explained 57.6 % of the total variance; specifically, Components 1 and 2 contributed 44.5% and 13.1 % of the variance respectively. These findings indicate that the Chinese version of the MacCAT-CR is a reliable and valid instrument to assess the decision-making capacity to consent to clinical research of patients with schizophrenia spectrum disorders.
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Palmer BW, Savla GN, Roesch SC, Jeste DV. Changes in capacity to consent over time in patients involved in psychiatric research. Br J Psychiatry 2013; 202:454-8. [PMID: 23661766 PMCID: PMC3669878 DOI: 10.1192/bjp.bp.112.121160] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 01/04/2013] [Accepted: 02/18/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Informed consent is a key element of ethical clinical research. Patients with serious mental illness may be at risk for impaired consent capacity. Corrective feedback improves within-session comprehension of consent-relevant information, but little is known about the trajectory of patients' comprehension after the initial enrolment session. AIMS To examine whether within-session gains in understanding after feedback were maintained between study visits and to examine stability of decisional capacity over time. METHOD This was a longitudinal, within-participants comparison of decisional capacity assessed at baseline, 1 week, 3 months, 12 months and 24 months in 161 people with schizophrenia or bipolar disorder. RESULTS Within-session gains from corrective feedback generally dissipated over each follow-up interval. Decisional capacity showed a general pattern of stability, but there was significant between-participant heterogeneity. Better neuropsychological performance was associated with better decisional capacity across time points. Positive symptoms of schizophrenia did not predict any aspects of decisional capacity, but general psychopathology, negative symptoms and depression evidenced some modest associations with certain subdomains of decisional capacity. CONCLUSIONS Informed consent may be most effectively construed as an ongoing dialogue with participants at each study visit.
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Affiliation(s)
- Barton W Palmer
- University of California, San Diego MC 0993, 9500 Gilman Drive, La Jolla CA 92093-0993, USA.
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Fischer BA, McMahon RP, Meyer WA, Slack DJ, Appelbaum PS, Carpenter WT. Participants with schizophrenia retain the information necessary for informed consent during clinical trials. J Clin Psychiatry 2013; 74:622-7. [PMID: 23842013 PMCID: PMC4482016 DOI: 10.4088/jcp.12m07997] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 10/16/2012] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Cognitive impairment is a characteristic of schizophrenia. This impairment may affect the retention of information required for ongoing knowledgeable participation in clinical trials. This study monitored retention of study-related knowledge-including assessment of therapeutic misconception-in people with stable, DSM-IV schizophrenia during participation in placebo-controlled clinical trials of adjunctive agents. Stability was defined as being on an antipsychotic with no change in medication or dose over the previous 4 weeks. METHOD This longitudinal study assessed retention of clinical trial-related consent information. Individuals enrolling in 1 of 8 clinical trials were approached for participation. Participants came from research clinics and community mental health centers. At baseline, clinical trial consent forms were reviewed and study knowledge assessed. Participants were randomized to follow-up assessments at weeks 1, 4, and 8; weeks 4 and 8; or at week 8 only. Clinical trial consent forms were not rereviewed at any follow-up visit. RESULTS Fifty-nine participants were enrolled; analysis included 52 participants with at least 1 follow-up visit. Study knowledge did not decrease meaningfully in any group. Therapeutic misconception was not observed in participants during the study. The group assessed most frequently demonstrated significant improvement over baseline (t44 = 3.43, P = .001). Retention of study knowledge was not related to symptoms but had a weak correlation with cognitive capacity (R = 0.28, P = .07). Performance did not differ between participants from research clinics and those from community mental health centers. CONCLUSIONS Clinically stable people with schizophrenia enrolling in a placebo-controlled adjunctive medication study, once determined to have capacity to consent to a clinical trial, retained appropriate study knowledge for at least 8 weeks. In the absence of a specific reason to suspect a loss of decisional capacity, there appears to be no need to routinely reevaluate participants during this type of clinical trial.
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Affiliation(s)
- Bernard A. Fischer
- Veterans Affairs Capital Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore, Maryland, USA,Department of Psychiatry, Maryland Psychiatric Research Center, University Of Maryland School of Medicine, Baltimore, Maryland, USA,Corresponding Author Address: Bernard A. Fischer, M.D., Maryland Psychiatric Research Center, P.O. Box 21247, Baltimore, MD 21228, , phone: 410.402.7113, fax: 410.402.7198
| | - Robert P. McMahon
- Department of Psychiatry, Maryland Psychiatric Research Center, University Of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Walter A. Meyer
- Department of Psychiatry, Maryland Psychiatric Research Center, University Of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Daniel J. Slack
- The Shriver Center, University of Maryland Baltimore County, Baltimore, Maryland, U.S.A
| | - Paul S. Appelbaum
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - William T. Carpenter
- Veterans Affairs Capital Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore, Maryland, USA,Department of Psychiatry, Maryland Psychiatric Research Center, University Of Maryland School of Medicine, Baltimore, Maryland, USA
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Aydin Er R, Sehiralti M, Aker AT. Preliminary Turkish study of psychiatric in-patients' competence to make treatment decisions. Asia Pac Psychiatry 2013; 5:E9-E18. [PMID: 23857795 DOI: 10.1111/appy.12000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 08/15/2012] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Competence is a prerequisite for informed consent. Patients who are found to be competent are entitled to accept or refuse the proposed treatment. In recent years, there has been an increased interest in studies examining competence for treatment in psychiatric patients. In this study, we aimed to investigate the decision-making competencies of inpatients with a range of psychiatric diseases. METHODS This study was carried out at the psychiatry clinic of Kocaeli University Hospital in Turkey from June 2007 to February 2008. Decision-making competence was assessed in 83 patients using the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). RESULTS The study groups consisted of patients with mood (39.8%), psychotic (27.7%) and anxiety disorders (18.1%), and alcohol/substance addiction (14.5%). There was a significant relation between decision-making competence and demographic and clinical characteristics. Appreciation of the given information was more impaired in psychotic disorder patients than in other patients, but understanding and reasoning of the given information was similar in all groups. DISCUSSION These results reveal the importance of evaluating decision-making competencies of psychiatric patients before any treatment or intervention is carried out to ascertain their ability to give informed consent to treatment. Institutional and national policies need to be determined and put into practice relating to the assessment and management of competence in patients with psychiatric disorders.
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Affiliation(s)
- Rahime Aydin Er
- Vocational School of Health, Kocaeli University, Kocaeli, Turkey.
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Raffard S, Fond G, Brittner M, Bortolon C, Macgregor A, Boulenger JP, Gely-Nargeot MC, Capdevielle D. Cognitive insight as an indicator of competence to consent to treatment in schizophrenia. Schizophr Res 2013; 144:118-21. [PMID: 23313358 DOI: 10.1016/j.schres.2012.12.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 12/07/2012] [Accepted: 12/19/2012] [Indexed: 11/25/2022]
Abstract
The processes underlying the ability to make decisions about recommended treatments remain poorly understood in schizophrenia. The aim of this study was to explore the relationships between capacity to consent to medication and cognitive biases in 60 schizophrenia patients. Main measures included the MacArthur Competence Assessment tool for Treatment (MacCAT-T) and the Beck Cognitive Insight Scale (BCIS). After Bonferroni's correction for multiple correlations, the Self-Reflectiveness dimension of the BCIS was significantly associated with the dimension "Reasoning" of the MacCAT-T. Cognitive therapy, by enhancing patients' Self-Reflectiveness and considering alternative explanations, could lead to better capacity to consent to treatment in schizophrenia.
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Affiliation(s)
- Stéphane Raffard
- Laboratory Epsylon, EA 4556, Montpellier, France; University Department of Adult Psychiatry, CHRU Montpellier, Montpellier, France.
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Mandarelli G, Parmigiani G, Tarsitani L, Frati P, Biondi M, Ferracuti S. The Relationship Between Executive Functions and Capacity to Consent to Treatment in Acute Psychiatric Hospitalization. J Empir Res Hum Res Ethics 2012; 7:63-70. [DOI: 10.1525/jer.2012.7.5.63] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the acknowledged influence of cognition on patients' capacity to consent to treatment, the specific neuropsychological domains involved remain elusive, as does the role of executive functions. We investigated possible associations between executive functions and decisional capacity in a sample of acute psychiatric inpatients. Patients were recruited and evaluated through the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the 24-item Brief Psychiatric Rating Scale (BPRS), the Mini-Mental State Examination (MMSE), and the Wisconsin Card Sorting Test (WCST). Patients with poor executive functioning performed worse in MacCAT understanding, appreciation, and expression of a choice, compared with good performers. These findings point to the importance of cognition in decisional capacity processes. In addition, the strong association found between learning abilities and informed consent decision-making provide empirical evidence indicating possible cognitive enhancement strategies that may improve psychiatric patients' competency.
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Ruissen AM, Widdershoven GAM, Meynen G, Abma TA, van Balkom AJLM. A systematic review of the literature about competence and poor insight. Acta Psychiatr Scand 2012; 125:103-13. [PMID: 21902676 DOI: 10.1111/j.1600-0447.2011.01760.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Formally, incompetence implies that a patient cannot meet the legal requirements for informed consent. Our aim was to review the scientific literature on the relationship between competence and insight in patients with psychiatric disorders, how competence and insight are connected in these patients and whether there are differences in competence and insight among patients with different disorders. METHOD A search in PubMed/Medline was performed. Articles were assessed on relevance criteria by two independent reviewers. Study design, population, variables, and outcomes were extracted. RESULTS Seven articles were included on studies of psychiatric inpatients and outpatients and of psychotic and non-psychotic patients. All studies used the MacArthur Competence Assessment Tool (MacCAT). All studies but one found a strong correlation between poor insight and incompetence. Psychotic patients with poor insight are very likely to be incompetent, and psychotic patients with adequate insight are generally competent. One well-executed study showed that in non-psychotic disorders, however, another relationship emerges; competence and insight do not completely overlap in these patients. CONCLUSION Most incompetent psychotic patients have poor insight, but non-psychotic patients with adequate insight were incompetent in a substantial number of cases. In sum: non-psychotic patients with adequate insight can be incompetent.
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Affiliation(s)
- A M Ruissen
- VU University Medical Centre, Medical Humanities, EMGO+ Institute for Health and Care Research, Amsterdam, the Netherlands.
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Gupta UC, Kharawala S. Informed consent in psychiatry clinical research: A conceptual review of issues, challenges, and recommendations. Perspect Clin Res 2012; 3:8-15. [PMID: 22347696 PMCID: PMC3275995 DOI: 10.4103/2229-3485.92301] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Obtaining informed consent in psychiatry clinical research involving subjects with diminished mental abilities and impaired consent capacity has been a challenge for researchers, posing many ethical concerns and procedural hurdles due to participants' cognitive deficits and impaired ability to judge reality. Regulations seem inadequate and provide limited guidance, not sufficient to address all the ethical issues inherent in different situations related to obtaining consent from decisionally impaired persons. Researchers are struggling to find a balance between risk-benefit ratio, research advancement, and autonomy of study subjects. Inspired to improve the consent process in psychiatry clinical research, many studies have been conducted focusing on various informed consent-related ethical concerns, with the aim of developing appropriate strategies and optimizing the informed consent procedure in psychiatry clinical research, overcoming the ethical concerns. This article critically reviews the various ethical issues and consent challenges, their underlying reasons, and investigates the appropriate strategies and practices needed to be adopted while obtaining informed consent from subjects with impaired consent capacity, participating in psychiatry clinical research.
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Affiliation(s)
- Umesh Chandra Gupta
- Sr. Research Scientist, Medical Affairs and Clinical Research, Fresenius Kabi India Pvt. Ltd., Gurgaon, India
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Abstract
Schizophrenia is a devastating illness, affecting approximately 1-2 % of the world population. Age of onset is generally between 20 and 30 years of age with a chronic, unremitting course for the duration of the patient's life. Although schizophrenia is among the most severe and debilitating illnesses known to medicine, its treatment has remained virtually unchanged for over 50 years. This chapter covers several major concepts in experimental drug development and delivery: (1) the concept of "typical" vs. "atypical" classifications for antipsychotic drugs as it relates to dosing; (2) the development of depot formulations for improved medication adherence; and (3) several promising areas for future therapeutic advances related to the methods and duration of drug administration. These areas include sublingual, injectable, and implantable drug delivery strategies that have the potential to effect rapid and dramatic improvements in schizophrenia outcomes.
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Affiliation(s)
- Cara R Rabin
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.
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Kaup AR, Dunn LB, Saks ER, Jeste DV, Palmer BW. Decisional capacity and consent for schizophrenia research. IRB 2011; 33:1-9. [PMID: 21932481 PMCID: PMC3245677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Background Despite substantial research on overall decision-making capacity (DMC) levels in schizophrenia, factors causing individuals to make errors during decision-making regarding research participation or treatment are relatively unknown. Methods We examined the responses of 84 middle-aged and older patients with schizophrenia or schizoaffective disorder on a structured DMC measure—the MacArthur Competence Assessment Tool for Clinical Research—to determine the frequency and apparent cause of patients’ errors. Results Most errors were due to difficulty recalling the disclosed information (seen in 65.5% of patients), particularly the study’s procedures, potential risks/discomforts, and purpose. Errors attributable to concrete thinking, thought disorder or other psychotic symptoms, or perceived coercion were rarer. Conclusions Informed consent procedures might be improved for this population by providing information in a way that facilitates learning and memory, such as iterative disclosure of the information, corrective feedback, and emphasis of key points (e.g., the study’s purpose, procedures, and potential risks).
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Affiliation(s)
- Allison R Kaup
- San Diego State University/University of California, San Diego, CA, USA
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Dawes SE, Jeste DV, Palmer BW. Cognitive profiles in persons with chronic schizophrenia. J Clin Exp Neuropsychol 2011; 33:929-36. [PMID: 21644139 DOI: 10.1080/13803395.2011.578569] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cognitive heterogeneity has been a key barrier to clarifying the neuropathologic underpinnings of schizophrenia. We used an idiographic method for cluster analysis of neuropsychological data from 144 middle-aged and older people with schizophrenia to characterize and group the patterns of relative (within-person) profiles of cognitive strength and weakness. Results indicated a 5-cluster solution as most appropriate, with relatively even distribution across the 5 clusters in terms of the proportion of patients in each cluster. Cognitive subtyping may be useful in imaging and genetic research on schizophrenia, as well as having practical utility in treatment planning and cognitive rehabilitation.
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Affiliation(s)
- Sharron E Dawes
- Department of Psychiatry, University of California, San Diego, La Jolla, USA
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Neuropsychological impairment corresponds with poor understanding of informed consent disclosures in persons diagnosed with major depression. Psychiatry Res 2011; 187:106-12. [PMID: 21126772 DOI: 10.1016/j.psychres.2010.10.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 10/16/2010] [Accepted: 10/25/2010] [Indexed: 11/24/2022]
Abstract
Incapacity to make decisions about medical treatment is associated with neuropsychological impairment in a variety of illnesses. Although cognitive deficits occur often in people with major depressive illness, little research has studied its association with decisional capacity. The present investigation examined ability to understand treatment disclosures, which is a core component of decisional capacity, in 31 inpatients with depression and 16 normal controls. Depressed inpatients with diminished neuropsychological function showed poor understanding of treatment disclosures compared to the control group. Nonetheless, with sufficient cueing, depressed inpatients with diminished neuropsychological function were able to display understanding that was equivalent to the control group. Exploratory regression analyses revealed that diminished new-learning correlated with poorer understanding. Implications of these results for clinical practice and medical research involving people with major depressive illness are discussed.
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Basso MR, Candilis PJ, Johnson J, Ghormley C, Combs DR, Ward T. Capacity to make medical treatment decisions in multiple sclerosis: a potentially remediable deficit. J Clin Exp Neuropsychol 2011; 32:1050-61. [PMID: 20446143 DOI: 10.1080/13803391003683062] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Ability to make decisions about medical treatment is compromised in significant numbers of people with neurological and psychiatric illness, and this incapacity frequently corresponds with compromised neuropsychological function. Although cognitive deficits occur often in people with multiple sclerosis (MS), no research has studied decisional capacity in that disease. The present investigation examined ability to understand treatment disclosures, which is a core component of decisional capacity, in 36 people with MS and 16 normal controls. MS patients with diminished neuropsychological function showed poor understanding of treatment disclosures compared to the control group, and diminished new learning and executive function correlated with poorer understanding. Nonetheless, with sufficient cuing, the MS patients with diminished neuropsychological function were able to display understanding that was equivalent to that of the control group. Implications of these results for clinical practice and medical research involving people with MS are discussed.
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Affiliation(s)
- Michael R Basso
- Department of Psychology, University of Tulsa, Tulsa, OK 74104, USA.
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Abstract
Impairments in patients with dementia and other disorders affecting cognition may have a negative impact on their capacity to provide consent to treatment or to participation in research. A growing literature confirms that even patients with mild cognitive impairment may experience decrements in decisional abilities, findings that are more pronounced still in the early stages of dementia. However, most patients with mild dementia probably remain competent to provide a valid consent to treatment or research, and even some patients with moderate dementia may retain capacity in particular circumstances. Clinical evaluation of decisional competence has been augmented by structured approaches, including reliable instruments that may be used in the clinical setting. To avoid needlessly depriving patients of their right to make health care decisions, evaluations should be designed to maximize patient performance. However, when substitute consent is necessary, state laws generally provide a range of options, including advance directives and familial consent.
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Affiliation(s)
- Paul S Appelbaum
- New York State Psychiatric Institute, Unit #122, 1051 Riverside Drive, New York, NY 10032, USA.
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De Marco MC, Sani G, Manfredi G, Pacchiarotti I, Savoja V, Balbi A, Mazzarini L, Borriello A, Kotzalidis GD, Tatarelli R, Girardi P, Ferracuti S. Assessment of the capacity to express informed consent for organ donation in patients with schizophrenia. J Forensic Sci 2010; 55:669-76. [PMID: 20345780 DOI: 10.1111/j.1556-4029.2010.01364.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In Italy, the "silent-consent" principle of donor's willingness regulates organ donation for postmortem transplantation, but civil incompetence excludes it. We investigated decisional capacity for organ donation for transplantation of 30 controls and 30 nonincompetent patients with schizophrenia as related to clinical symptoms, cognition, and functioning. Assessments were carried out through the Competence for Donation Assessment Scale (CDAS), Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms, Life Skills Profile (LSP), Raven's Colored Progressive Matrices (RCPM), Wisconsin Card Sorting Test, Rey RI, Rey RD, and Visual Search. Patients and controls differed on the CDAS Understanding and Choice Expression areas. Patients showed significant inverse bivariate correlations between CDAS Understanding and scores on total BPRS, LSP self-care scale, and RCPM cognitive test. Our results show that decisional capacity for participating in research does not predict decisional capacity for postmortem organ donation in patients with schizophrenic or schizoaffective psychosis; hence, before judging consent for donation, patients must be provided with enhanced information to better understand this delicate issue.
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Abstract
This chapter addresses the current state of affairs regarding proposed mechanism of action for antipsychotic medications and how this mechanism relates to dosing and delivery strategies. The initial portion describes the history of antipsychotic medication, including key discoveries that contribute to the dopamine hypothesis of schizophrenia and provide evidence that dopamine D2 receptor antagonism remains the most copasetic explanation for both determination of dose and degree of efficacy for current antipsychotic medications. Early observations regarding the unique properties of clozapine and how those observations led to the misconception and misnomer of atypicality are also discussed. Subsequent sections relate the dosing of available medications using chlorpromazine equivalents, with a discussion of non-D2-related mechanisms to antipsychotic effects. The balance of the chapter explores the temporal pattern of receptor occupancy as a key determinant of antipsychotic effectiveness, noting that continuous infusion would present the optimal method of treatment. In addition to the pharmacodynamic benefits of continuous long-term delivery systems, the incidence, causes, and clinical consequences of poor adherence are addressed. These observations are then discussed in the context of clinical studies and meta-analyses, demonstrating superiority of long-term depot preparations over oral administration. However, despite overwhelming evidence in favor of long-term delivery systems, few options are available to provide such ideal medication delivery profiles. Barriers to creating traditional depot preparations for a large number of antipsychotic agents, as well as efforts to address these limitations with polymer-based microspheres are described. The potential extension of current formulations to very long-term delivery implants using biodegradable and nonbiodegradable platforms is then described. Benefits as well as limitations of such systems are discussed with respect to clinical and ethical issues as well as a brief description of potential regulatory and logistic barriers to developing better delivery options. In summary, this chapter describes the basis for relating the dose of all existing antipsychotic medications to dopamine D2 receptor affinity and the potential contribution of continuous occupancy to enhanced efficacy through superior biological effects and improved adherence.
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Affiliation(s)
- Cara R Rabin
- Child Psychiatry Branch, National Institute of Mental Health, Bethesda, MD 20892, USA.
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Abstract
PURPOSE OF REVIEW Neuroethics is a recently emerging field that deals with predominantly empirical and practical issues of ethics in neuroscience. In contrast, theoretical and methodological considerations have rather been neglected and thus what may be called theoretical neuroethics. RECENT FINDINGS The review focuses on informed consent and moral judgment as examples of empirical neuroethics and norm-fact circularity and method-based neuroethics as issues of a theoretical neuroethics. SUMMARY It is argued that we need to consider theoretical and methodological issues in order to develop neuroethics as a distinct discipline, which as such can be distinguished from both philosophy/ethics and neuroscience.
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Owen GS, David AS, Richardson G, Szmukler G, Hayward P, Hotopf M. Mental capacity, diagnosis and insight in psychiatric in-patients: a cross-sectional study. Psychol Med 2009; 39:1389-1398. [PMID: 18940026 PMCID: PMC7611628 DOI: 10.1017/s0033291708004637] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Mental capacity is now a core part of UK mental health law and clinicians will increasingly be expected to assess it. Because it is a legal concept there is a need to clarify associations with variables that clinicians are more familiar with, especially insight. METHOD In this cross-sectional study we recruited consecutive psychiatric admissions to the Maudsley Hospital, London. We carried out structured assessments of decision making using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), resulting in a clinical judgement about capacity status. We analysed associations with a range of sociodemographic and clinical variables, including insight score on the Expanded Schedule for the Assessment of Insight (SAI-E). The same variables were compared in an analysis stratified according to diagnostic group: psychotic disorders/bipolar affective disorder (BPAD)/non-psychotic disorders. RESULTS Psychotic disorders and manic episodes of BPAD are most strongly associated with incapacity. In such patients, insight is the best discriminator of capacity status. In patients with non-psychotic disorders, insight is less strongly associated with capacity; in this group depressed mood discriminates capacity status whereas it does not in psychotic disorders. Cognitive performance does not discriminate capacity status in patients with psychotic disorders. CONCLUSIONS Mental capacity has complex relationships with psychopathological variables, and these relationships are different according to diagnostic group. Insight is the best discriminator of capacity status in psychotic disorders and BPAD but not in non-psychotic disorders.
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Affiliation(s)
- G S Owen
- Departments of Psychological Medicine and Psychiatry, Institute of Psychiatry, King's College London, UK.
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What do we know about neuropsychological aspects of schizophrenia? Neuropsychol Rev 2009; 19:365-84. [PMID: 19639412 PMCID: PMC2745531 DOI: 10.1007/s11065-009-9109-y] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 07/02/2009] [Indexed: 11/05/2022]
Abstract
Application of a neuropsychological perspective to the study of schizophrenia has established a number of important facts about this disorder. Some of the key findings from the existing literature are that, while neurocognitive impairment is present in most, if not all, persons with schizophrenia, there is both substantial interpatient heterogeneity and remarkable within-patient stability of cognitive function over the long-term course of the illness. Such findings have contributed to the firm establishment of neurobiologic models of schizophrenia, and thereby help to reduce the social stigma that was sometimes associated with purely psychogenic models popular during parts of the 20th century. Neuropsychological studies in recent decades have established the primacy of cognitive functions over psychopathologic symptoms as determinants of functional capacity and independence in everyday functioning. Although the cognitive benefits of both conventional and even second generation antipsychotic medications appear marginal at best, recognition of the primacy of cognitive deficits as determinants of functional disability in schizophrenia has catalyzed recent efforts to develop targeted treatments for the cognitive deficits of this disorder. Despite these accomplishments, however, some issues remain to be resolved. Efforts to firmly establish the specific neurocognitive/neuropathologic systems responsible for schizophrenia remain elusive, as do efforts to definitively demonstrate the specific cognitive deficits underlying specific forms of functional impairment. Further progress may be fostered by recent initiatives to integrate neuropsychological studies with experimental neuroscience, perhaps leading to measures of deficits in cognitive processes more clearly associated with specific, identifiable brain systems.
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Jeste DV, Palmer BW, Golshan S, Eyler LT, Dunn LB, Meeks T, Glorioso D, Fellows I, Kraemer H, Appelbaum PS. Multimedia consent for research in people with schizophrenia and normal subjects: a randomized controlled trial. Schizophr Bull 2009; 35:719-29. [PMID: 18245061 PMCID: PMC2696362 DOI: 10.1093/schbul/sbm148] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Limitations of printed, text-based, consent forms have long been documented and may be particularly problematic for persons at risk for impaired decision-making capacity, such as those with schizophrenia. We conducted a randomized controlled comparison of the effectiveness of a multimedia vs routine consent procedure (augmented with a 10-minute control video presentation) as a means of enhancing comprehension among 128 middle-aged and older persons with schizophrenia and 60 healthy comparison subjects. The primary outcome measure was manifest decisional capacity (understanding, appreciation, reasoning, and expression of choice) for participation in a (hypothetical) clinical drug trial, as measured with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and the University of California San Diego (UCSD) Brief Assessment for Capacity to Consent (UBACC). The MacCAT-CR and UBACC were administered by research assistants kept blind to consent condition. Additional assessments included standardized measures of psychopathology and cognitive functioning. Relative to patients in the routine consent condition, schizophrenia patients receiving multimedia consent had significantly better scores on the UBACC and on the MacCAT-CR understanding and expression of choice subscales and were significantly more likely to be categorized as being capable to consent than those in the routine consent condition (as categorized with several previously established criteria). Among the healthy subjects, there were few significant effects of consent condition. These findings suggest that multimedia consent procedures may be a valuable consent aid that should be considered for use when enrolling participants at risk for impaired decisional capacity, particularly for complex and/or high-risk research protocols.
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