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Marcó-García S, Ariyo K, Owen GS, David AS. Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis. Psychol Med 2024; 54:1074-1083. [PMID: 38433596 DOI: 10.1017/s0033291724000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Decision-making capacity (DMC) among psychiatric inpatients is a pivotal clinical concern. A review by Okai et al. (2007) suggested that most psychiatric inpatients have DMC for treatment, and its assessment is reliable. Nevertheless, the high heterogeneity and mixed results from other studies mean there is considerable uncertainty around this topic. This study aimed to update Okai's research by conducting a systematic review with meta-analysis to address heterogeneity. We performed a systematic search across four databases, yielding 5351 results. We extracted data from 20 eligible studies on adult psychiatric inpatients, covering DMC assessments from 2006 to May 2022. A meta-analysis was conducted on 11 papers, and a quality assessment was performed. The study protocol was registered on PROSPERO (ID: CRD42022330074). The proportion of patients with DMC for treatment varied widely based on treatment setting, the specific decision and assessment methods. Reliable capacity assessment was feasible. The Mini-Mental State Examination (MMSE), Global Assessment of Function (GAF), and Brief Psychiatric Rating Scale (BPRS) predicted clinical judgments of capacity. Schizophrenia and bipolar mania were linked to the highest incapacity rates, while depression and anxiety symptoms were associated with better capacity and insight. Unemployment was the only sociodemographic factor correlated with incapacity. Assessing mental capacity is replicable, with most psychiatric inpatients able to make treatment decisions. However, this capacity varies with admission stage, formal status (involuntary or voluntary), and information provided. The severity of psychopathology is linked to mental capacity, though detailed psychopathological data are limited.
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Affiliation(s)
- Silvia Marcó-García
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain
- Etiopathogenesis and treatment of severe mental disorders (MERITT), Sant Joan de Déu Research Institute, Sant Joan de Déu Foundation, Barcelona, Spain
- Department of Social Psychology and Quantitative Psychology, Faculty of Psychology, University of Barcelona, 08035 Barcelona, Spain
| | - Kevin Ariyo
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Gareth S Owen
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony S David
- Division of Psychiatry, UCL Institute of Mental Health, University College London, London, UK
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Marcó-García S, Ribas-Muñoz N, Guilera G, Balsells-Mejía S, Huerta-Ramos E. RECAPACITA PROJECT: Impact of the New York Convention on capacity modification judgments in persons with severe mental disorders: A comparative study using mixed methodology. MEDICINE, SCIENCE, AND THE LAW 2023:258024231206863. [PMID: 37817639 DOI: 10.1177/00258024231206863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
In 2013, Spain aligned its capacity modification processes (CM) legislation with the UN Convention on the rights of persons with disabilities, specifically for individuals with severe mental disorders (SMD). The reforms replaced incapacity verdicts with support provision and introduced the term "CM". However, the social impact of these changes remains uncertain. The RECAPACITA project was initiated to generate knowledge on SMD and CM, and this study aims to investigate modifications in CM sentences and associated terminology. Using a qualitative-quantitative methodology, content analysis was conducted on 56 sentences from individuals with SMD. Terminology analysis utilized 19 sentences to achieve information saturation. A comparison was made between sentences prior to 2013 and those spanning 2014 to 2023, analyzing the data through ANOVA and Bonferroni tests (significance level: 0.05). The analysis revealed that psychiatric illness, its evolution, lack of self-governance, and economic management were frequently mentioned aspects in the sentences. However, no significant correlations were found. Qualitatively, mentions of self-governance were more prevalent in sentences before 2013. Conversely, after 2013, there was an increased focus on substances use, lack of insight and medical adherence, and the need for support in daily life. The term "incapable person" appeared in 100% of the sentences, indicating no differences in terminology. The study suggests that current CM sentences provide increasingly individualized information, addressing the specific support needs of individuals. To enhance future legal proceedings, incorporating neuroscience in studying SMD individuals and reconsidering terminology based on Convention guidelines is recommended.
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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, Barcelona, Spain
| | | | - Georgina Guilera
- Department of Social Psychology and Quantitative Psychology, Faculty of Psychology, University of Barcelona, 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, 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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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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Marazia C, Rucci P, Fangerau H, Voßberg D, Rolfes V, Iozzino L, Iommi M, Gosek P, Heitzman J, Ferrari C, Macis A, Markiewicz I, Picchioni M, Salize HJ, Stompe T, Wancata J, Appelbaum PS, de Girolamo G. Treatment Decision-Making Capacity in Forensic vs Non-forensic Psychiatric Patients: A European Comparison. SCHIZOPHRENIA BULLETIN OPEN 2022; 3:sgac037. [PMID: 39144784 PMCID: PMC11205899 DOI: 10.1093/schizbullopen/sgac037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
Background Consent to treatment is a cornerstone of medical ethics and law. Nevertheless, very little empirical evidence is available to inform clinicians and policymakers regarding the capacities of forensic patients with schizophrenia spectrum disorders (SSDs) to make decisions about their treatment, with the risk of clinical and legal inertia, silent coercion, stigmatization, or ill-conceived reforms. Study Design In this multinational study, we assessed and compared with treatment-related decisional capacities in forensic and non-forensic patients with SSD. 160 forensic and 139 non-forensic patients were used in Austria, Germany, Italy, Poland, and England. Their capacity to consent to treatment was assessed by means of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Multiple generalized linear regression models were used to identify the socio-demographic and clinical variables associated with MacCAT-T scores. Study Results In total, 55 forensic (34.4%) and 58 non-forensic patients (41.7%) showed high treatment-related decisional capacity, defined as scoring ≥75% of the maximum scores for the understanding, appreciation and reasoning, and 2 for expressing a choice. Forensic patients showed differences in their capacity to consent to treatment across countries. Of all socio-demographic and clinical variables, only "social support" was directly relevant to policy. Conclusions Forensic patients have treatment-related decisional capacities comparable with their non-forensic counterparts. Social contacts might provide a substantial contribution towards enhancing the decisional autonomy of both forensic and non-forensic patients, hence improving the overall quality and legitimacy of mental health care.
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Affiliation(s)
- Chantal Marazia
- Department of the History, Philosophy and Ethics of Medicine, Medical Faculty, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Heiner Fangerau
- Department of the History, Philosophy and Ethics of Medicine, Medical Faculty, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Dilara Voßberg
- Department of the History, Philosophy and Ethics of Medicine, Medical Faculty, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Vasilija Rolfes
- Department of the History, Philosophy and Ethics of Medicine, Medical Faculty, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Laura Iozzino
- Unit of Epidemiological Psychiatry and Evaluation, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Marica Iommi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Pawel Gosek
- Department of Forensic Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Janusz Heitzman
- Department of Forensic Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Clarissa Ferrari
- Unit of Statistics, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Ambra Macis
- Unit of Statistics, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Inga Markiewicz
- Department of Forensic Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Marco Picchioni
- Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- St Magnus Hospital, Haslemere, UK
| | - Hans Joachim Salize
- Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Heidelberg, Germany
| | - Thomas Stompe
- Clinical Division of Social Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Johannes Wancata
- Clinical Division of Social Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Paul S Appelbaum
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Giovanni de Girolamo
- Unit of Epidemiological Psychiatry and Evaluation, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
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Pons EV, Salvador‐Carulla L, Calcedo‐Barba A, Paz S, Messer T, Paccardi B, Zeller SL. The capacity of schizophrenia and bipolar disorder individuals to make autonomous decisions about pharmacological treatments for their illness in real life: A scoping review. Health Sci Rep 2020; 3:e179. [PMID: 32782974 PMCID: PMC7415958 DOI: 10.1002/hsr2.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND AIM Having decision making capacity is central to the exercise of autonomy in mental health care. The objective of this scoping review is to summarize the evidence on the capacity of people with schizophrenia or bipolar disorder to make decisions about their treatment in real life to support medical practice. METHODS Systematic search of observational studies on the assessment of capacity of patients with schizophrenia, psychosis, or bipolar disorder to make healthcare and treatment-related decisions, conducted in any clinical setting published up to January 31, 2020 was performed. Free text searches and medical subject headings in English were combined in PubMed, Scopus, CINAHL, and PsycInfo. Publications were selected as per inclusion and exclusion criteria. The Newcastle-Ottawa Scale for observational studies was used to assess the quality of publications. RESULTS Thirty publications were reviewed. According to the Newcastle-Ottawa Scale criteria, the publications reviewed were good quality. Findings showed that more than 70% of schizophrenia and schizoaffective disorder outpatients understood treatment options at the point of making decisions about their illness and healthcare. Patients treated voluntarily had considerably better scores for decisional capacity than those treated involuntarily. The burden of psychiatric symptoms could compromise decisional capacity temporarily. Decision-making capacity improved over time from admission to discharge from hospital, and with treatment among psychiatry inpatients. Schizophrenia and bipolar disorder patients could be as competent as nonpsychiatric individuals in making decisions about their treatments in everyday life. CONCLUSIONS This scoping review provides a body of evidence for healthcare professionals in need of assessing the capacity of schizophrenia and bipolar disorder patients for autonomously decide about their treatments. Decisional capacity judgements should consider variations in capacity over time and be based on the type of decision to be made, the severity of symptoms, and the specific phase of the mental disorder.
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Affiliation(s)
- Enric Vincens Pons
- Department of PsychiatryParc Sanitari Sant Joan de Déu, Sant Boi de LlobregatBarcelonaSpain
| | - Luis Salvador‐Carulla
- Centre for Mental Health ResearchResearch School of Population Health, College of Health and Medicine, Australian National UniversityCanberraAustralia
| | - Alfredo Calcedo‐Barba
- Department of Psychiatry, Hospital Gregorio MarañónMedical School at the Universidad Complutense de MadridMadridSpain
| | | | - Thomas Messer
- Department of PsychiatryDanuviusklinikPfaffenhofenGermany
| | - Bruno Paccardi
- Psychiatric UnitSanta Chiara University Hospital, University of PisaPisaItaly
| | - Scott L. Zeller
- Department of PsychiatryUniversity of CaliforniaCaliforniaUSA
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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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Zlodre J, Yiend J, Burns T, Fazel S. Coercion, competence, and consent in offenders with personality disorder. PSYCHOLOGY, CRIME & LAW : PC & L 2015; 22:315-330. [PMID: 27284235 PMCID: PMC4896379 DOI: 10.1080/1068316x.2015.1109086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Competence to consent to treatment has not previously been examined in a personality disorder cohort without comorbid mental disorder. We examined competence and coercion in 174 individuals diagnosed with severe personality disorder using two validated tools (the MacArthur Competence Assessment Tool for Treatment and the MacArthur Coercion Assessment Scale - Short Form). Competence was not categorically impaired, but there were variations within the sample on dimensional competence measures. Further, there were significant negative correlations between experienced coercion and competence. Higher coercion scores were associated with two components of competence: lower understanding and reasoning. Patients who consented to treatment had higher scores on competence measures and experienced less coercion. These findings suggest that therapeutic approaches that decrease experienced coercion and increase competence may increase the engagement of individuals diagnosed with severe personality disorders in treatment.
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Affiliation(s)
- J Zlodre
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - J Yiend
- Institute of Psychiatry, King's College London, London, UK
| | - T Burns
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - S Fazel
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
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Lepping P, Stanly T, Turner J. Systematic review on the prevalence of lack of capacity in medical and psychiatric settings. Clin Med (Lond) 2015; 15:337-43. [PMID: 26407382 PMCID: PMC4952795 DOI: 10.7861/clinmedicine.15-4-337] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Recent court cases in England and Wales have refocused attention on patients' decision-making capacity to consent. Little is known about the prevalence of incapacity across specialities but decision-making capacity is likely to be overestimated by clinicians. The aim of this systematic review is to estimate the prevalence of incapacity to consent to treatment or admission in different medical and psychiatric settings, and compare the two. We conducted an electronic search following PRISMA principles and included 35 studies in psychiatric and 23 studies in medical settings. The 58 included studies revealed 70 data sets across all settings. For psychiatric settings the weighted average proportion of patients with incapacity was 45% (95% confidence interval (CI) 39-51%). For medical settings, the weighted average proportion of patients with incapacity was 34% (95% CI 25-44%). The two groups are not significantly different from each other in terms of the proportion of incapacity (p=0.92). A considerable number of medical and psychiatric patients lack capacity to make treatment and assessment decisions. Clinicians should be more alert to the possibility that their patients may lack decision-making capacity. Assessment of capacity should be frequent using the appropriate legal frameworks to act in the best interest of patients.
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Affiliation(s)
- Peter Lepping
- Betsi Cadwaladr University Local Health Board, and Centre for Mental Health and Society, Wrexham, UK, and Mysore Medical College and Research Institute, Mysore, India
| | | | - Jim Turner
- Betsi Cadwaladr University Local Health Board and Bangor University, UK
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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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Callaghan S, Ryan C, Kerridge I. Risk of suicide is insufficient warrant for coercive treatment for mental illness. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:374-385. [PMID: 23816377 DOI: 10.1016/j.ijlp.2013.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Mental health laws in many jurisdictions currently permit coercive treatment for persons with mental illness who are thought to be at risk of harm to themselves or others. These laws are often used to provide involuntary treatment to persons who are thought to be at risk of suicide. In this article we argue that legislated coercive psychiatric treatment should not be triggered by an assessment of the likelihood of harm, including a likelihood of suicide, but should be available only where a person is found to lack capacity to make their own decisions about their own health risks, after appropriate support has been given. We suggest that current opposition to this approach may find its origin in factors including uncertainties about the idea of vulnerability and its relationship to capacity as well as tendency to minimise the real costs of psychiatric treatment and coercion against the aim of suicide prevention. Given the limits of suicide risk assessment, we argue that a public policy that allows involuntary preventative detention of competent persons thought to be at risk of suicide, places too great a burden on all persons living with mental illness to be justified. We suggest that we are better placed to serve the interests and respect the human rights of people with mental illness if we respect and support the right of persons to make decisions, rather than focussing on perceived vulnerabilities and calculations of suicide risk.
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Affiliation(s)
- Sascha Callaghan
- Centre for Values, Ethics and the Law in Medicine, University of Sydney, Australia.
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11
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Malhi GS. Buds of May. Aust N Z J Psychiatry 2013; 47:405-6. [PMID: 23653058 DOI: 10.1177/0004867413486555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
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