Changes in capacity to consent over time in patients involved in psychiatric research

Capacity to Consent in Healthcare: A Systematic Review and Meta-Analysis Comparing Patients with Bipolar Disorders and Schizophrenia Spectrum Disorders

Background: Mental capacity is a fundamental aspect that enables patients to fully participate in various healthcare procedures. To assist healthcare professionals (HCPs) in assessing patients' capacity, especially in the mental health field, several standardized tools have been developed. These tools include the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), and the Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD). The core dimensions explored by these tools include Understanding, Appreciation, Reasoning, and Expression of a choice. Objective: This meta-analysis aimed to investigate potential differences in decision-making capacity within the healthcare context among groups of patients with bipolar disorders (BD) and schizophrenia spectrum disorders (SSD). Methods: A systematic search was conducted on Medline/Pubmed, and Scopus. Additionally, Google Scholar was manually inspected, and a manual search of emerging reviews and reference lists of the retrieved papers was performed. Eligible studies were specifically cross-sectional, utilizing standardized assessment tools, and involving patients diagnosed with BD and SSD. Data from the studies were independently extracted and pooled using random-effect models. Hedges' g was used as a measure for outcomes. Results: Six studies were identified, with three studies using the MacCAT-CR, two studies the MacCAT-T, and one the CAT-PAD. The participants included 189 individuals with BD and 324 individuals with SSD. The meta-analysis revealed that patients with BD performed slightly better compared to patients with SSD, with the difference being statistically significant in the domain of Appreciation (ES = 0.23, 95% CI: 0.01 to 0.04, p = 0.037). There was no statistically significant difference between the two groups for Understanding (ES = 0.09, 95% CI:-0.10 to 0.27, p = 0.352), Reasoning (ES = 0.18, 95% CI: -0.12 to 0.47, p = 0.074), and Expression of a choice (ES = 0.23, 95% CI: -0.01 to 0.48, p = 0.60). In the sensitivity analysis, furthermore, when considering only studies involving patients in symptomatic remission, the difference for Appreciation also resulted in non-significant (ES = 0.21, 95% CI: -0.04 to 0.46, p = 0.102). Conclusions: These findings indicate that there are no significant differences between patients with BD and SSD during remission phases, while differences are minimal during acute phases. The usefulness of standardized assessment of capacity at any stage of the illness should be considered, both for diagnostic-therapeutic phases and for research and advance directives. Further studies are necessary to understand the reasons for the overlap in capacity between the two diagnostic categories compared in this study.

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

BACKGROUND

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

STUDY DESIGN

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

STUDY RESULTS

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

CONCLUSIONS

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

Returning Individual Research Results to Vulnerable Individuals

Although issues associated with returning individual research results to study participants have been well explored, these issues have been less thoroughly investigated in vulnerable individuals and populations. Considerations regarding return of research results to these individuals and populations, including how best to ensure truly informed consent, how to minimize the risks and benefits of the return of research results, and how best to ensure justice may differ from those of the population at large. This article discusses the issues and challenges associated with the return of individual research results (such as genomic, proteomic, or other biomarker data) to potentially vulnerable individuals and populations, including those who may be vulnerable for cognitive, communicative, institutional, social, deferential, medical, economic, or social reasons. It explores factors that should be considered in the design, conduct, and oversight of ethically responsible research involving the return of research results to vulnerable individuals and populations and discuss recommendations for those engaged in this work.

Inclusion of people living with Alzheimer's disease or related dementias who lack a study partner in social research: Ethical considerations from a qualitative evidence synthesis

BACKGROUND

Because use of a study partner (proxy decision-maker) to give informed consent on behalf of someone living with Alzheimer's disease or related dementias (ADRD) is common in nearly all clinical research, people living with ADRD who lack a study partner are regularly excluded from participation. Social research presents different opportunities and risks than clinical research. We argue that guidelines developed for the latter may be unduly restrictive for social research and, further, that the automatic exclusion of people living with ADRD presents separate ethical challenges by failing to support extant decision-making capacity and by contributing to underrepresentation in research.

PURPOSE

The study objective was to identify key components related to including cognitively vulnerable participants who lack a study partner in social research.

RESEARCH DESIGN/STUDY SAMPLE

We conducted an adaptive qualitative evidence synthesis (QES) and subsequent content analysis on 49 articles addressing capacity and research consent for potentially cognitively compromised individuals, to include people living with ADRD, who lack a study partner.

RESULTS

We identified four major topic areas: defining competency, capacity, and consent; aspects of informed consent; strategies to assess comprehension of risks associated with social research; and risks versus benefits.

CONCLUSIONS

Based on findings, we suggest new and ethically appropriate ways to determine capacity to consent to social research, make consent processes accessible to a population experiencing cognitive challenges, and consider the risks of excluding a growing population from research that could benefit millions.

Capacity to provide informed consent among adults with bipolar disorder

BACKGROUND

Identifying correlates of capacity to provide informed consent among individuals with bipolar disorder is essential for patient protection. As part of a clinical trial involving approved, standard treatments, we investigated relationships between clinical characteristics and capacity to provide informed consent in adults with bipolar disorder using the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). After administering the MacCAT-CR, continuing participants in the trial were capable of and provided informed consent.

METHODS

Trained, board-certified psychiatrists administered the MacCAT-CR to potential study participants (N = 50) after they provided informed consent, but prior to initiation of study procedures.

RESULTS

Higher Schedule for Assessment of Positive Symptoms (SAPS) scores were significantly correlated with worse MacCAT-CR Understanding and Appreciation (p < 0.04) subscale scores; lower Hamilton Depression Rating Scale (HDRS) scores and higher Clinical Global Impression-Severity (CGI-S) scores were significantly correlated with worse Reasoning and Understanding subscale scores (p < 0.03); and patients with comorbid substance use disorders (SUD) had better Appreciation and Reasoning subscale scores (p < 0.05).

LIMITATIONS

The MacCAT-CR identifies areas where participants need explanation. However, there is not a predetermined score to indicate understanding of study procedures and therefore input from a trained clinician is needed to determine capacity to provide informed consent.

CONCLUSIONS

Our findings suggest that certain measures of illness severity are associated with lower levels of capacity to provide informed consent among adults with bipolar disorder. This study provides important information for clinicians and researchers to consider when obtaining informed consent in this population.

Fitness to plead: Development and validation of a standardised assessment instrument

The ability of an individual to participate in courtroom proceedings is assessed by clinicians using legal ‘fitness to plead’ criteria. Findings of ‘unfitness’ are so rare that there is considerable professional unease concerning the utility of the current subjective assessment process. As a result, mentally disordered defendants may be subjected unfairly to criminal trials. The Law Commission in England and Wales has proposed legal reform, as well as the utilisation of a defined psychiatric instrument to assist in fitness to plead assessments. Similar legal reforms are occurring in other jurisdictions. Our objective was to produce and validate a standardised assessment instrument of fitness to plead employing a filmed vignette of criminal proceedings. The instrument was developed in consultation with legal and clinical professionals, and was refined using standard item reduction methods in two initial rounds of testing (n = 212). The factorial structure, test-retest reliability and convergent validity of the resultant instrument were assessed in a further round (n = 160). As a result of this iterative process a 25-item scale was produced, with an underlying two-factor structure representing the foundational and decision-making abilities underpinning fitness to plead. The sub-scales demonstrate good internal consistency (factor 1: 0·76; factor 2: 0·65) and test-retest stability (0·7) as well as excellent convergent validity with scores of intelligence, executive function and mentalising abilities (p≤0·01 in all domains). Overall the standardised Fitness to Plead Assessment instrument has good psychometric properties. It has the potential to ensure that the significant numbers of mentally ill and cognitively impaired individuals who face trial are objectively assessed, and the courtroom process critically informed.

Ethics in Psychiatric Research: Issues and Recommendations

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.

A brief assessment of capacity to consent instrument in acutely intoxicated emergency department patients

OBJECTIVE

The aim of this study was to determine to what extent acute alcohol intoxication effects capacity to assent, consent, or refuse research participation.

METHODS

This was a prospective, observation study performed at our inner city, county hospital with >100,000 annual emergency department visits. Non-pregnant, English speaking patients older than 18 with evidence of acute alcohol intoxication were considered eligible. After medical screening, a trained research associate presented the study version of the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC) tool. The primary outcome was the number of patients able to correctly respond to all 10 questions.

RESULTS

Of 642 screened patients, 415 patients were enrolled and completed the tool. The mean alcohol concentration was 227mg/dL (range 25-500mg/dL). Sixteen patients (3.9%) answered all 10 questions correctly; by definition of the UBACC, these patients were deemed to possess capacity to consent. Mean alcohol concentrations in the capacity group were lower than in those lacking capacity; 182mg/dL (SD 6.7) versus 229mg/dL, (SD 7.9). Of the 287 patients who were interviewed upon sobriety at discharge, 182 patients (63.4%) did not recall completing the questionnaire.

CONCLUSIONS

While intoxicated emergency department patients are able to complete the questionnaire, the majority do not possess capacity to provide informed consent to research. A minority of participants remember involvement once they have achieved sobriety, exception from informed consent protocols are needed to perform emergency research in this population.

Mental Capacity Assessments Among Inpatients Referred to the Consultation-Liaison Psychiatry Unit at a University Hospital in Bangkok, Thailand

Clinicians routinely assess patients' mental capacity on a daily basis, but a more thorough assessment may be needed in complex cases. We aimed to identify the characteristics of inpatients in a general hospital, who were referred to a liaison psychiatry service for mental capacity assessment, reasons for the referrals, and the factors associated with their mental capacity. A 6-year retrospective study (2008-2013) was conducted using data collected routinely (e.g., age, gender, diagnosis, Thai Mental State Examination score, reasons for the referral, and the outcome of capacity assessment) on referrals for mental capacity assessment to a Consultation-liaison Psychiatry Unit at a university hospital in Thailand. Among 6194 consecutive referrals to the liaison-psychiatry services, only 0.6 % [n = 37, mean age (SD), 59.83 (20.42)] were referred for capacity assessment, 43.24 % of which lacked mental capacity. The most common requests from referring physicians were for assessment of testamentary capacity (15 assessed, 53.33 % lacking capacity), financial management capacity (14 assessed, 50 % lacking capacity), and capacity to consent to treatment (9 assessed, 22.22 % lacking capacity). Delirium, rather than dementia or other mental disorders, was associated with mental incapacity (p < 0.001) and being more dependent during the admission (p = 0.048). There were no significant differences for mean age (p = 0.257) or Thai Mental State Examination score (p = 0.206). The main request from referring clinicians was to assess testamentary capacity. Delirium and being more dependent during the admission were associated with lack of mental capacity, whereas age and dementia were not.

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

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

Functional mental capacity, treatment as usual and time: magnitude of change in secure hospital patients with major mental illness

BACKGROUND

Decision making ability can change with time, depending on mental or physical health. Little is known about the factors that determine this change and the relationship of capacity to time. As a pilot for studies using functional mental capacities as an outcome measure, we sought to quantify this relationship measuring change over time using competence assessment tools, and rating scales for symptoms and global function.

METHODOLOGY

We assessed 37 inpatients in a secure psychiatric hospital. All patients met the diagnostic and statistical manual of mental disorders-fourth edition and International classification of diseases, 10th edition criteria for an Axis 1 mental illness, all with psychosis. Patients were interviewed twice a mean of 323 days apart (median 176 days range 17-1221 days). The MacArthur competence assessment tools for consent to treatment (MacCAT-T) and fitness to plead (MacCAT-FP) were used to quantify functional capacity along with the Positive and Negative Syndrome Scale (PANSS) and global assessment of function (GAF) scale. A comparison was also made between those patients prescribed clozapine in comparison to other antipsychotics.

RESULTS

The number judged by treating psychiatrists to lack capacity either to make a treatment choice or to plead in court fell from 35 to 8%. Change was greatest for those admitted within the previous 9 months. The measures of capacity improved between time 1 and time 2 for both consent to treatment and fitness to plead. The measures of capacity improved with positive symptoms within the PANSS and with GAF scores. Those with shorter lengths of stay at baseline had the greatest improvements in the MacCAT-FP scores. Effect sizes were medium or large (0.3-0.7+). As expected, patients prescribed clozapine had larger changes in functional mental capacities and larger effect sizes than those prescribed other psychotropics. The results show a strong relationship between the clinicians' assessment of capacity and structured rating scales.

CONCLUSIONS

We have shown that there is an improvement in capacity scores with time. More research is needed to compare the effect of treatment on capacity at fixed time intervals. It would also be helpful to look at a more general patient population.