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McWilliams A, Ariyo K, David AS, Owen GS. Mental capacity assessment in the multi-professional real world: a qualitative study of six areas of uncertainty. Wellcome Open Res 2024; 9:221. [PMID: 38911900 PMCID: PMC11190650 DOI: 10.12688/wellcomeopenres.20952.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 06/25/2024] Open
Abstract
Background The Mental Capacity Act 2005 of England and Wales is a ground-breaking piece of legislation with reach into healthcare, social care and legal settings. Professionals have needed to develop skills to assess mental capacity and handle malign influence, but it is unclear how assessments are implemented in real world settings. Our previously reported survey found professionals juggling competing resources in complex systems, often struggling to stay up to date with law.The current follow-up study uses one-to-one interviews of professionals to characterise in detail six areas of uncertainty faced when assessing mental capacity, whilst suggesting ways to make improvements. Methods Forty-four healthcare, social care and legal professionals were interviewed, using a semi-structured topic guide. Transcripts were analysed using framework analysis: a qualitative technique built to investigate healthcare policy. Results Our topic guide generated 21 themes. In relation to the six areas of uncertainty: 1) Many participants stressed the importance of capturing a holistic view, adding that their own profession was best-placed for this - although a medical diagnosis was often needed. 2) The presumption of capacity was a laudable aim, though not always easy to operationalise and occasionally being open to abuse. 3) There was cautious interest in psychometric testing, providing a cognitive context for decisions. 4) Undue influence was infrequent, but remained under-emphasised in training. 5) Multi-professional assessments were common, despite doubts about fitting these within local resources and the law. 6) Remote assessment was generally acceptable, if inadequate for identifying coercion. Conclusions Practical constraints and competing demands were reported by professionals working within real world systems. Assessment processes must be versatile, equally applicable in routine and emergency settings, across diverse decisional types, for both generalist and specialist assessors, and able to handle coercion. Recognising these challenges will guide development of best practices in assessment and associated policy.
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Affiliation(s)
- Andrew McWilliams
- Mental Health, Ethics and Law Research Group, Department of Psychological Medicine, King's College London, London, SE5 8AF, UK
- Metacognition Group, Wellcome Centre for Human Neuroimaging, University College London, 12 Queen Square, London, WC1N 3BG, UK
- Child and Adolescent Mental Health Services, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
| | - Kevin Ariyo
- Mental Health, Ethics and Law Research Group, Department of Psychological Medicine, King's College London, London, SE5 8AF, UK
| | - Anthony S. David
- UCL Institute of Mental Health, Department of Psychiatry, University College London, London, W1T 7NF, UK
| | - Gareth S. Owen
- Mental Health, Ethics and Law Research Group, Department of Psychological Medicine, King's College London, London, SE5 8AF, UK
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Raffard S, Bayard S, Tattard P, Laraki Y, Capdevielle D. Cross-sectional study on the dissociation of decision-making capacity for antipsychotic treatment and COVID-19 vaccination in individuals with schizophrenia. Front Psychiatry 2023; 14:1308666. [PMID: 38156326 PMCID: PMC10753010 DOI: 10.3389/fpsyt.2023.1308666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Objective Decision-making capacity for treatment is impaired in schizophrenia but it remains unknown if schizophrenia affects distinct decision-making capacities differently. Methods In this study, we assessed concomitantly two decision-making capacities (i.e., antipsychotic treatment and COVID-19 vaccination) in 27 schizophrenia patients. Sociodemographic variables, psychotic symptoms, global cognition and insight were also assessed. Results We found that among individuals incompetent to consent to antipsychotic treatment, one-third had preserved capacity to consent to vaccination. No significant associations between the two different decision-making capacities were found. Psychotic symptoms and cognition were associated with the capacity to consent to antipsychotic treatment and to vaccination, respectively. Conclusion Clinicians should be aware that capacity to consent to treatment is not unidimensional and vary across domains in individuals with schizophrenia. Being incompetent regarding one treatment does not mean to be incompetent for another treatment in this clinical population.
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Affiliation(s)
- Stéphane Raffard
- Université Paul Valéry Montpellier 3, EPSYLON EA 4556, Montpellier, France
- University Department of Adult Psychiatry, CHU Montpellier, Montpellier, France
- FondaMental Academic Advanced Center of Expertise for Schizophrenia (FACE-SZ), Créteil, France
| | - Sophie Bayard
- Université Paul Valéry Montpellier 3, EPSYLON EA 4556, Montpellier, France
| | - Philippe Tattard
- University Department of Adult Psychiatry, CHU Montpellier, Montpellier, France
| | - Yasmine Laraki
- Université Paul Valéry Montpellier 3, EPSYLON EA 4556, Montpellier, France
- University Department of Adult Psychiatry, CHU Montpellier, Montpellier, France
| | - Delphine Capdevielle
- University Department of Adult Psychiatry, CHU Montpellier, Montpellier, France
- FondaMental Academic Advanced Center of Expertise for Schizophrenia (FACE-SZ), Créteil, France
- IGF, Université de Montpellier, CNRS, INSERM, Montpellier, France
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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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Provencal Levesque O, Vandyk A, Vanderspank-Wright B, Kaluzienski M, Jacob JD. Engaging in resuscitation status conversations in psychiatry: A qualitative study of nurses' perspectives. J Psychiatr Ment Health Nurs 2021; 28:995-1004. [PMID: 34322957 DOI: 10.1111/jpm.12791] [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: 01/19/2021] [Revised: 06/30/2021] [Accepted: 07/19/2021] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Discussion and documentation of a patient's resuscitation status are essential aspects of any hospital admission, and yet, they seldomly occur in psychiatry. Nurses play an important role in resuscitation status determination by being an information broker, supporter and advocate. Persons with mental illness may be competent to engage in the determination of their resuscitation status and deserve the same respect and autonomy as other patients during this process. There are no published qualitative studies exploring healthcare providers experiences in initiating resuscitation status conversations in the psychiatric setting. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: An in-depth qualitative understanding of the complexity of resuscitation status determination in psychiatry. The shared experiences of nurses enacting their role in resuscitation status determination with patients admitted to psychiatry. The challenges of implementing a 'one-size fits all' approach to resuscitation status policies, and the ways in which depression and/or suicidal ideation influence the process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Role clarity and improved communication between providers about resuscitation status determination in psychiatry are needed. Hospital policies for resuscitation status determination must account for the psychiatric context to ensure patients' goals of care are known and upheld. Nurses working in psychiatry should initiate and more readily engage in resuscitation status conversations. ABSTRACT: Introduction Patients with mental illness experience stigma and marginalization, which affects the quality of their health care. In most settings, end-of-life decisions, including goals of care, must be discussed with all patients upon hospital admission, including determining cardiopulmonary resuscitation preferences in the event of a medical emergency. Despite this requirement, these conversations do not routinely occur in inpatient psychiatry. By default, patients become a 'full code status', mandating life-sustaining interventions. Aim To explore how and why resuscitation status conversations occur, or do not occur, in inpatient psychiatry from the perspectives of healthcare providers. Method Qualitative descriptive study using focus groups with nurses working in psychiatry. Results Nurses' experiences with initiating and engaging in resuscitation status conversations related to Working in Psychiatry, which represents the current practices and the participants' views of the nursing role; Caring for Psychiatric Patients, which describes how fluctuating competency and suicidality influence determination; and The Influence of Physical Health Status, which details how differences in physical health status affect how healthcare providers engage in resuscitation status determination. Discussion Although the importance of completing resuscitation status conversations with patients admitted to psychiatry was expressed by participants, they seldomly occur. There is ambiguity about when and how to determine patient wishes. Implications for practice Tailored strategies are needed to ensure patients' rights to self-determination are upheld when they are admitted to psychiatry. Nurses working in this setting would benefit from education, training and support to adequately initiate and engage in these conversations.
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Affiliation(s)
| | - Amanda Vandyk
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Mark Kaluzienski
- Department of Mental Health, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jean Daniel Jacob
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
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van Elburg A, Danner UN, Sternheim LC, Lammers M, Elzakkers I. Mental Capacity, Decision-Making and Emotion Dysregulation in Severe Enduring Anorexia Nervosa. Front Psychiatry 2021; 12:545317. [PMID: 33776810 PMCID: PMC7991306 DOI: 10.3389/fpsyt.2021.545317] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 01/28/2021] [Indexed: 12/20/2022] Open
Abstract
Severe and Enduring Anorexia Nervosa (SE-AN) is a chronic eating disorder characterized by long-term starvation and its physical and psychological sequelae, and severe loss of quality of life. Interactions between neurobiological changes caused by starvation, vulnerability (personality) traits, and eating behaviors play a role. Several other factors, such as increased fear and decreased social cognition, have also been found in relation to SE-AN. With this in mind, we aim to add to the understanding of SE-AN by introducing the concept of mental capacity (MC), which refers to the ability to understand and process information-both on a cognitive and an emotional level-and then make a well-informed choice. MC may be an important construct within the context of SE-AN. Furthermore, we will argue how impaired decision-making processes may underlie, fuel, or contribute to limited MC in SE-AN. We will speculate on the importance of dysfunctional emotion processing and anxiety-related processes (e.g., a high intolerance of uncertainty) and their potential interaction with decision-making. Lastly, we will propose how these aspects, which to our knowledge have previously received little attention, may advise research and treatment or help in dealing with the "want but cannot" situation of life-threatening AN.
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Affiliation(s)
- Annemarie van Elburg
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands.,Rintveld Center for Eating Disorders, Altrecht Mental Health Institute, Zeist, Netherlands
| | - Unna Nora Danner
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands.,Rintveld Center for Eating Disorders, Altrecht Mental Health Institute, Zeist, Netherlands
| | - Lot Catharina Sternheim
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | | | - Isis Elzakkers
- Rintveld Center for Eating Disorders, Altrecht Mental Health Institute, Zeist, Netherlands
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Khalily MT, Rehman AU, Bhatti MM, Hallahan B, Ahmad I, Mehmood MI, Khan SH, Khan BA. Stakeholders' perspective on mental health laws in Pakistan: A mixed method study. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2021; 74:101647. [PMID: 33246231 DOI: 10.1016/j.ijlp.2020.101647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/20/2020] [Accepted: 11/05/2020] [Indexed: 06/11/2023]
Abstract
The present study explored awareness and opinions pertaining to mental health legislation in Pakistan in the context of the United Nation Convention on Rights of People with Disabilities (UNCRPD) through a mixed method research design. In the quantitative arm of the study, a structured questionnaire examined awareness and opinions of key stakeholders pertaining to national mental health legislation. In the qualitative arm, face-to-face interviews further elaborated stakeholders perspectives pertaining to these topics with thematic analysis conducted. Stakeholders demonstrated a good awareness of legislation pertaining to guardianship (83.0 %) appointment of property managers (89.7%) and salary or pension entitlements (89.2%). Compared to other stakeholders, patients had less understanding of processes pertaining to involuntary admission (χ2 = 20.54, p = 0.02) and appointing a guardian (χ2 = 34.67, p < 0.01). High consensus across stakeholders was noted for processes of involuntary detention (83.5%) and appointment of guardians or property managers (80.0%) albeit patients demonstrated less agreement on these topics (p <0.01). Minimal support was noted for an involuntary patient to be discharged solely on a psychiatrist's recommendation (25.4%). Thematic analysis indicated fifteen emergent themes: 1) Alienation/ Seclusion; 2) Capacity building; 3) Communication Gap; 4) Conflict of interests; 5) Discomfort at hospital; 6) Economic burden; 7) Government's liability; 8) Family involvement; 9) Imbalance; 10) Acceptance of Legal Incapacity; 11) Legal reforms; 12) Patient centred environment; 13) Quality assurance; 14) Under developed infrastructure and 15) Potential unethical practices. This study advocates for increased patient involvement in collaborative decision making with mental health professionals and the creation of more appropriate inpatient treatment environments.
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Affiliation(s)
| | - Aziz Ur Rehman
- Department of Law, International Islamic University, Islamabad, Pakistan
| | - Mujeeb Masud Bhatti
- Department of Psychology, International Islamic University, Islamabad, Pakistan
| | - Brian Hallahan
- Department of Psychiatry, National University of Ireland, Galway, Ireland
| | - Irshad Ahmad
- Department of Psychology, International Islamic University, Islamabad, Pakistan.
| | | | - Shamsher Hayat Khan
- Department of Psychology, International Islamic University, Islamabad, Pakistan
| | - Bilal Ahmed Khan
- Department of Psychology, International Islamic University, Islamabad, Pakistan
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Evaluation of the capacity to consent to treatment among patients with bipolar disorder: Comparison between the acute psychopathological episode and the stable mood phase. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2020. [DOI: 10.1016/j.jadr.2020.100037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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De Las Cuevas C, Mundal I, Betancort M, Lara-Cabrera ML. Assessment of shared decision-making in community mental health care: Validation of the CollaboRATE. Int J Clin Health Psychol 2020; 20:262-270. [PMID: 32994799 PMCID: PMC7501445 DOI: 10.1016/j.ijchp.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/23/2020] [Indexed: 01/20/2023] Open
Abstract
Background/Objective CollaboRATE is a 3-item self-report measure of the patient experience of shared decision-making (SDM) process. The objective of this study is to assess the psychometric properties of CollaboRATE in community mental health care. Method A cross-sectional study was conducted at a Community Mental Health Center of the Canary Islands Health Service. Two hundred and fifty consecutive psychiatric outpatients were invited to participate. Of those, 191 accepted (76.40% of response rate) and completed the CollaboRATE, the Control Preferences Scale (CPS), and a form with sociodemographic and clinical variables. Results Exploratory factor analysis ratified the unidimensionality of the measure. High internal consistency was found (α Cronbach = .95, Guttman's λ = .93, and ω = .95). Strong positive correlations (p < .0001) were found between the CollaboRATE and the CPS. Only 39.80% of respondents gave the best possible score on CollaboRATE. Conclusions This study provides evidence for the reliability and validity of the Spanish version of the CollaboRATE as a measure of SDM. The measure is quick to complete and feasible for use in outpatient mental health care. At present, a significative number of psychiatric outpatients are not involved in SDM. The use of this measure in psychiatric routine care can be a key tool in assessing and implementing SDM.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, Universidad de La Laguna, Spain.,Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, Spain
| | - Ingunn Mundal
- Faculty of Health and Social Sciences, Molde University College, Norway.,Kristiansund Community Mental Health Centre, Division of Mental Health, Møre and Romsdal Hospital Trust, Norway
| | - Moisés Betancort
- Department of Clinical Psychology, Psychobiology, and Methodology, Universidad de La Laguna, Spain
| | - Mariela L Lara-Cabrera
- Department of Research and Development, Division of Mental Health, St Olav's University Hospital, Norway.,Dept. of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Norway.,Tiller Community Mental Health Centre, Division of Psychiatry, St. Olav's University Hospital, Norway
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Shalev D, Fields L, Shapiro PA. End-of-Life Care in Individuals With Serious Mental Illness. PSYCHOSOMATICS 2020; 61:428-435. [PMID: 32660874 PMCID: PMC7290196 DOI: 10.1016/j.psym.2020.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 01/26/2023]
Abstract
Background Approximately 4.5% of the population live with serious mental illness (SMI), a term referring to mental health disorders that are chronic, impair function, and require ongoing treatment. People living with SMI are at risk of premature mortality relative to people without SMI. Chronic medical illnesses contribute significantly to mortality among individuals with SMI. The standard of care for individuals with serious medical illnesses includes palliative care. However, the provision of palliative care has not been operationalized for individuals with SMI. Objectives To review existing data on end-of-life and palliative care for individuals with serious medical illness and comorbid serious mental illness. To operationalize the role of the consultation-liaison (C-L) psychiatrist in such care, with a particular eye towards redressing disparities. Methods In this narrative review, we draw upon a review of the literature on end-of-life and palliative care provision for individuals with serious medical illness and comorbid serious medical illness. We also draw upon the experiences of the authors in formulating best practices for the care of such patients. Results Individuals with SMI are at risk of suboptimal end-of-life care. Patient, clinician, and system-level factors all contribute to disparities including decreased access to palliative care, uneven continued engagement with mental health services, and low rates of advance care planning. C-L psychiatrists can use their expertise at the intersection of medicine and psychiatry to address such disparities by (1) correcting misassumptions, (2) promoting advance care planning, (3) engaging long-term caregivers, (4) recognizing social needs, (5) ensuring ongoing access to psychiatric treatment, and (6) addressing suffering. Conclusions There are significant disparities in the end-of-life care of individuals with SMI. C-L psychiatrists have expertise to ally with medical providers and redress these disparities.
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Affiliation(s)
- Daniel Shalev
- Department of Psychiatry, Columbia University, New York, NY.
| | - Lauren Fields
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
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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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Dembo J, Schuklenk U, Reggler J. "For Their Own Good": A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) where Mental Illness Is the Sole Underlying Condition. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:451-456. [PMID: 29635929 PMCID: PMC6099778 DOI: 10.1177/0706743718766055] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Canada is approaching its federal government's review of whether patients should be eligible for medical assistance in dying (MAID) where mental illness is the sole underlying medical condition, and when "natural death" is not "reasonably foreseeable". For those opposed, arguments involve the following themes: capacity, value of life, vulnerability, stigma, irremediability, and the role of physicians. It has also been suggested that those who are able-bodied should have to kill themselves, even though suicide may be painful, lonely, and violent. Opponents of MAID for severe, refractory suffering due to mental illness imply that it is acceptable to remove agency from such patients on paternalistic grounds. After years of efforts to destigmatise mental illness, these kinds of arguments effectively declare all patients with mental illness, regardless of capacity, unable to make considered choices for themselves. The current paper argues that decisions about capacity must be made on an individual-patient basis. Given the rightful importance granted to respect for patient autonomy in liberal democracies, the wholesale removal of agency advocated by opponents of a permissive MAID regime is difficult to reconcile with Canadian constitutional values.
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Affiliation(s)
- Justine Dembo
- 1 University of Toronto, Toronto, ON, Canada.,2 Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Udo Schuklenk
- 3 Department of Philosophy, Watson Hall 309, Queen's University, Kingston, ON, Canada
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Elzakkers IFFM, Danner UN, Grisso T, Hoek HW, van Elburg AA. Assessment of mental capacity to consent to treatment in anorexia nervosa: A comparison of clinical judgment and MacCAT-T and consequences for clinical practice. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2018; 58:27-35. [PMID: 29853010 DOI: 10.1016/j.ijlp.2018.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 01/22/2018] [Accepted: 02/13/2018] [Indexed: 06/08/2023]
Abstract
Informed consent requires adequate mental capacity to consent to treatment. Mental capacity (MC) to consent to treatment refers to the ability to make medical decisions. MC is assessed in a general psychiatric interview, but this clinical assessment is known to overestimate mental capacity in patients and the inter rater reliability is low. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) has emerged as the gold standard to assess mental capacity to consent to treatment. The MacCAT-T is a semi-structured interview designed to aid clinicians in this assessment and has shown good inter rater reliability in patients with schizophrenia and other mental disorders, but has hardly been studied in patients with anorexia nervosa. Patients with anorexia nervosa (AN) regularly avoid treatment, even when severely ill and discussion includes assessing MC to consent to treatment. The aim of this study is to compare clinical judgment and the MacCAT-T in evaluating MC in patients with AN which in turn may influence use of the MacCAT-T in daily practice. In a sample of 70 consecutively referred severely ill patients with AN with a mean BMI of 15.5 kg/m2 and a mean duration of illness of 8.6 years, clinical assessment of MC by experienced psychiatrists and the outcome of the MacCAT-T interview were compared. Agreement (κ-value) was calculated. Agreement between clinical assessment and outcome of the MacCAT-T was questionable (κ 0.23). Unlike in other psychiatric populations, clinicians judged a high proportion of patients with AN as having diminished MC. The MacCAT-T can be useful in assessing MC in AN when used in addition to clinical judgment to aid clinicians in complex cases. Why clinicians judge a relatively high proportion of patients with AN as having diminished MC, in contrast to lower proportions in other psychiatric disorders, is an area in need of further research.
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Affiliation(s)
- Isis F F M Elzakkers
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands
| | - Unna N Danner
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands; Utrecht University, Department of Psychology, The Netherlands
| | - Thomas Grisso
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hans W Hoek
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands; Parnassia Psychiatric Institute, The Hague, The Netherlands; Department of Psychiatry, University Medical Center Groningen, The Netherlands; Department of Epidemiology, Mailman School of Public Health, Columbia University New York, USA
| | - Annemarie A van Elburg
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands; Utrecht University, Department of Psychology, The Netherlands.
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Abstract
Psychiatric research has increased remarkably over recent decades to help in understanding the current trends and better therapeutic options for illness. On the other hand, there is also a trend toward higher rates of retraction of published papers in the recent years. Ethics is required to maintain and increase the overall quality and morality of research. Psychiatric research faces several unique ethical challenges. Ethical guidelines are very important tool of research which safeguards participants; however, there is a dearth of such guidelines in India. The present paper aims to review available ethical issues and guidelines pertaining to psychiatric research. A search was conducted on Pubmed using search terms (e.g., "ethics," "psychiatry," "research"). Relevant studies were selected for the review after manual screening of title/abstract. Additional sources were referred to using cross references and Google Scholar. Psychiatric research has several important ethical issues which are different from other medical disciplines. These issues are related to informed consent, confidentiality, conflict of interest, therapeutic misconception, placebo related, vulnerability, exploitation, operational challenges, among others. The current paper has made several recommendations to deal with ethical challenges commonly faced in psychiatric research. The ethical guidelines are utmost needed for Indian psychiatric research. Specific guidelines are lacking pertaining to psychiatric research. The issues and recommendations merit a further discussion and consideration.
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Affiliation(s)
- Shobhit Jain
- Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Pooja Patnaik Kuppili
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
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Bertrand E, van Duinkerken E, Landeira-Fernandez J, Dourado MCN, Santos RL, Laks J, Mograbi DC. Behavioral and Psychological Symptoms Impact Clinical Competence in Alzheimer's Disease. Front Aging Neurosci 2017; 9:182. [PMID: 28670272 PMCID: PMC5472652 DOI: 10.3389/fnagi.2017.00182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 05/24/2017] [Indexed: 11/13/2022] Open
Abstract
Decision-making is considered a fundamental aspect of personal autonomy and can be affected in psychiatric and neurologic diseases. It has been shown that cognitive deficits in dementia impact negatively on decision-making. Moreover, studies highlighted impaired clinical competence in neuropsychiatric disorders, such as schizophrenia and bipolar disorder. In this context, the current study explored the relationship between behavioral and psychological symptoms of dementia (BPSD) and clinical competence, especially the capacity to consent to treatment, in Alzheimer's disease (AD). Seventy-one patients with mild to moderate AD participated, completing assessments for capacity to consent to treatment, general cognition and neuropsychiatric disturbances. For each neuropsychiatric symptom, patients with and without the particular disturbance were compared on the different subscales of the MacArthur Competence Tool for Treatment (MacCAT-T; Understanding, Appreciation, Reasoning and Expression). The results showed that patients presenting delusions, as well as apathetic patients, had a lower ability to express a clear treatment choice compared to patients without these symptoms. By contrast, patients with dysphoria/depression had higher scores on this variable. Additionally, AD patients with euphoria had more difficulties discussing consequences of treatment alternatives compared to patients without this disturbance. None of the differences were confounded by global cognition. There were no between-group differences in clinical decision-making for patients with hallucinations, agitation/aggression, anxiety, irritability, disinhibition and aberrant motor behavior. These findings highlight the importance of taking BPSD into account when assessing decision-making capacity, especially clinical competence, in AD. Furthermore, reducing BPSD may lead to better clinical competence in patients with AD, as well as to improvements in patients and caregivers' quality of life.
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Affiliation(s)
- Elodie Bertrand
- Department of Psychology, Pontifícia Universidade Católica - Rio (PUC-Rio)Rio de Janeiro, Brazil
| | - Eelco van Duinkerken
- Department of Psychology, Pontifícia Universidade Católica - Rio (PUC-Rio)Rio de Janeiro, Brazil.,Department of Medical Psychology, VU University Medical CenterAmsterdam, Netherlands.,Diabetes Center/Department of Internal Medicine, VU University Medical CenterAmsterdam, Netherlands
| | - J Landeira-Fernandez
- Department of Psychology, Pontifícia Universidade Católica - Rio (PUC-Rio)Rio de Janeiro, Brazil
| | - Marcia C N Dourado
- Institute of Psychiatry-Center for Alzheimer's Disease, Federal University of Rio de Janeiro (UFRJ)Rio de Janeiro, Brazil
| | - Raquel L Santos
- Institute of Psychiatry-Center for Alzheimer's Disease, Federal University of Rio de Janeiro (UFRJ)Rio de Janeiro, Brazil
| | - Jerson Laks
- Institute of Psychiatry-Center for Alzheimer's Disease, Federal University of Rio de Janeiro (UFRJ)Rio de Janeiro, Brazil.,Post Graduation Program on Translational Biomedicine, Universidade do Grande Rio (Unigranrio)Caxias, Brazil
| | - Daniel C Mograbi
- Department of Psychology, Pontifícia Universidade Católica - Rio (PUC-Rio)Rio de Janeiro, Brazil.,Institute of Psychiatry, Psychology & Neuroscience, King's College LondonLondon, United Kingdom
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15
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Fernandez C, Kennedy HG, Kennedy M. The recovery of factors associated with decision-making capacity in individuals with psychosis. BJPsych Open 2017; 3:113-119. [PMID: 28507770 PMCID: PMC5415675 DOI: 10.1192/bjpo.bp.116.004226] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There is limited data on the recovery of factors associated with decisional capacity in patients with psychosis. AIMS To study the relationship between changes in mental capacity, symptoms and global functioning using structured measures during treatment for psychosis. METHOD Fifty-six patients with psychosis were assessed for capacity to consent to treatment on admission and at 6 and 12 weeks following treatment. The MacArthur Competence Assessment Tool - Treatment, the Positive and Negative Symptom Scale and the Global Assessment of Functioning Scale were used to measure mental capacities, symptom severity and global functioning respectively. Treating consultants rated capacity to consent, masked to these measures. RESULTS Greater impairments on all measures were found in patients assessed as lacking capacity. These improved with treatment over 12 weeks with significant effect sizes (0.5 to 0.6). Stronger correlations between mental capacities, positive symptoms (-0.47) and global functioning (0.56) were noted in the first 6 weeks. CONCLUSIONS Impairments in capacity in acute stages of psychosis are related to symptom severity and functional impairment. They improve during treatment, particularly in the first 6 weeks. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Affiliation(s)
- Colin Fernandez
- , MSc, MRCPsych, St Patrick's University Hospital, Dublin, Ireland
| | - Harry G Kennedy
- , MD, FRCPsych, Academic Department of Psychiatry, University of Dublin, Trinity College, Dublin, Ireland; National Forensic Mental Health Service, Central Mental Hospital, Dublin, Ireland
| | - Miriam Kennedy
- , PhD, MRCPsych, St Patrick's University Hospital, Dublin, Ireland; Academic Department of Psychiatry, University of Dublin, Trinity College, Dublin, Ireland
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Stovell D, Wearden A, Morrison AP, Hutton P. Service users’ experiences of the treatment decision-making process in psychosis: A phenomenological analysis. PSYCHOSIS-PSYCHOLOGICAL SOCIAL AND INTEGRATIVE APPROACHES 2016. [DOI: 10.1080/17522439.2016.1145730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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17
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Allen NG, Khan JS, Alzahri MS, Stolar AG. Ethical Issues in Emergency Psychiatry. Emerg Med Clin North Am 2015; 33:863-74. [DOI: 10.1016/j.emc.2015.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Chatterjee S, Kieselbach B, Naik S, Kumar S, John S, Balaji M, Koschorke M, Dabholkar H, Varghese M, Patel V, Thornicroft G, Thara R. Customising informed consent procedures for people with schizophrenia in India. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1527-36. [PMID: 25735517 DOI: 10.1007/s00127-015-1037-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/19/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is little information on how the ethical and procedural challenges involved in the informed participation of people with schizophrenia in clinical trials are addressed in low- and middle-income countries (LMICs). The informed consent procedure used in the collaborative community care for people with schizophrenia in India (COPSI) RCT was developed keeping these challenges in mind. We describe the feasibility of conducting the procedure from the trial, researcher and participants perspectives and describe the reasons for people consenting to participate in the trial or refusing to do so. METHODS Three sources of information were used to describe the feasibility of the COPSI consent procedure: key process indicators for the trial perspective, data from a specially designed post-interview form for participant's observations and focus group discussion (FGD) with the research interviewers. Categorical data were analysed by calculating frequencies and proportions, while the qualitative data from the FGD, and the reasons for participation or refusal were analysed using a thematic content analysis approach. FINDINGS 434 people with schizophrenia and their primary caregiver(s) were approached for participation in the trial. Consent interviews were conducted with 332, of whom 303 (91%) agreed to participate in the trial. Expectation of improvement was the most common reason for agreeing to participate in the trial, while concerns related to the potential disclosure of the illness, especially for women, were an important reason for refusing consent. CONCLUSIONS The COPSI consent procedure demonstrates preliminary, observational information about the feasibility of customising informed consent procedures for people with schizophrenia LMIC contexts. This and other similar innovations need to be refined and rigorously tested to develop evidence-based guidelines for informed consent procedures in such settings.
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Affiliation(s)
| | | | | | | | - Sujit John
- Schizophrenia Research Foundation, Chennai, India.
| | | | | | | | - Mathew Varghese
- National Institute of Mental Health and Neurosciences, Bengaluru, India.
| | - Vikram Patel
- Sangath, Goa, India. .,London School of Hygiene and Tropical Medicine, London, UK. .,Centre for Global Mental Health, London, UK. .,Centre for Mental Health, Public Health Foundation of India, New Delhi, India.
| | - Graham Thornicroft
- Institute of Psychiatry, Kings' College, London, UK. .,Centre for Global Mental Health, London, UK.
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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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End-of-life (care) perspectives and expectations of patients with schizophrenia. Arch Psychiatr Nurs 2013; 27:246-52. [PMID: 24070994 DOI: 10.1016/j.apnu.2013.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 04/23/2013] [Accepted: 05/05/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Schizophrenia is a disabling and life-shortening psychiatric disorder due to disease, medication, and lifestyle-related factors. It is therefore not unreasonable to assume that existential themes are important for these patients. METHODS Transcripts of 20 patients were coded and analyzed thematically, using a modified grounded theory approach in the exploration of perspectives and expectations of end-of-life (care). RESULTS No fear of death, skilled companionship and preserving quality of life were major themes in the interviews. CONCLUSION This study showed that patients, despite emotional flattening and cognitive deficits, find the possibility to discuss end-of-life topics reassuring and some even therapeutic.
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