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Kreniske P, Hoffman S, Ddaaki W, Nakyanjo N, Spindler E, Ssekyewa C, Isabirye D, Nakubulwa R, Proscovia N, Daniel L, Haba N, Maru M, Thompson J, Chen IS, Nalugoda F, Ssekubugu R, Lutalo T, Ott MA, Santelli JS. Capacity to Consent to Research Among Adolescent-Parent Dyads in Rakai, Uganda. J Pediatr 2022:S0022-3476(22)01020-4. [PMID: 36402433 DOI: 10.1016/j.jpeds.2022.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/11/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the cognitive capacity of early, middle, and late adolescents and their parents or guardians to provide informed consent to a population-based cohort study. STUDY DESIGN Adolescent-parent/guardian dyads including 40 early (n = 80; 10-14 years), 20 middle (15-17 years), and 20 late (18-19 years) adolescents were recruited from the Rakai Community Cohort Study, an open demographic cohort in Uganda. Participants were administered the MacArthur Competence Assessment Tool for Clinical Research, a structured open-ended assessment; interviews were recorded and transcribed. Twenty transcripts were scored independently by two coders; the intraclass correlation coefficient was 0.89. The remaining interviews were scored individually. We compared mean scores for early and middle/late adolescents using a one-sided t test and score differences between parent/guardian and adolescent dyads using two-sided paired t tests. RESULTS Early adolescents (mean score, 28.8; 95% CI, 27.1-30.5) scored significantly lower (P < .01) than middle/late adolescents (32.4; 31.6-33.1). In paired dyad comparisons, we observed no statistically significant difference in scores between parents/guardians and middle/late adolescents (difference, -0.2; 95% CI, -1.0-0.6). We found a statistically significant difference in scores between parents/guardians and early adolescents (difference, 3.0; 95% CI, 1.2-4.8). CONCLUSIONS The capacity of adolescents-of different ages and in diverse settings-to comprehend risks, benefits, and other elements of informed consent is a critical but understudied area in research ethics. Our findings support the practice of having middle and late adolescents provide independent informed consent for sexual and reproductive health studies. Early adolescents may benefit from supported decision-making approaches.
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Affiliation(s)
- Philip Kreniske
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY.
| | - Susie Hoffman
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | | | | | - Esther Spindler
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY
| | | | | | | | | | - Lee Daniel
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY
| | - Nao Haba
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY
| | - Mahlet Maru
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY
| | - Julia Thompson
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | - Ivy S Chen
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | | | | | - Tom Lutalo
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - Mary A Ott
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - John S Santelli
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY
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Fisher CB, Puri LI, Macapagal K, Feuerstahler L, Ahn JR, Mustanski B. Competence to Consent to Oral and Injectable PrEP Trials Among Adolescent Males Who Have Sex with Males. AIDS Behav 2021; 25:1606-1618. [PMID: 33247336 PMCID: PMC8052255 DOI: 10.1007/s10461-020-03077-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 01/16/2023]
Abstract
Adherence to oral pre-exposure prophylaxis (PrEP) is challenging for adolescent males who have sex with males (AMSM). Once adult trials comparing oral to longer lasting injectable PrEP are completed, there will be a need for adolescent studies. However, lack of data on adolescent consent capacity may sustain guardian permission requirements identified as a barrier to AMSM participation in prior PrEP trials. This online study assessed AMSM's (14-17 years) consent capacity for these trials, comparing performance to MSM (18-19 years) for whom guardian permission is not required. Applying the MacCAT-CR, participants (N = 214) viewed a video and mock consent form followed by open-ended and yes/no items. Cognitive diagnostic models and means testing analyses supported AMSM capacity to consent to these trials: 16-17 and most 14-15 year-olds, demonstrated consent understanding, appreciation and reasoning at 18-19 year-old levels. Data also identified vulnerabilities requiring attention during informed consent.
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Affiliation(s)
- Celia B Fisher
- Center for Ethics Education, HIV/Drug Abuse Prevention Research Ethics Institute, and Department of Psychology, Fordham University, Dealy Hall, Bronx, NY, 10458, USA.
| | | | - Kathryn Macapagal
- Institute for Sexual and Gender Minority Health and Wellbeing & Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing & Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Klein CC, Jolson MB, Lazarus M, Masterson B, Blom TJ, Adler CM, DelBello MP, Strakowski SM. Capacity to provide informed consent among adults with bipolar disorder. J Affect Disord 2019; 242:1-4. [PMID: 30153563 DOI: 10.1016/j.jad.2018.08.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/20/2018] [Accepted: 08/12/2018] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Christina C Klein
- Division of Bipolar Disorders Research, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Michelle B Jolson
- Division of Bipolar Disorders Research, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Meg Lazarus
- Division of Bipolar Disorders Research, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian Masterson
- Division of Bipolar Disorders Research, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Thomas J Blom
- Division of Bipolar Disorders Research, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Caleb M Adler
- Division of Bipolar Disorders Research, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Melissa P DelBello
- Division of Bipolar Disorders Research, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Hostiuc S, Rusu MC, Negoi I, Drima E. Testing decision-making competency of schizophrenia participants in clinical trials. A meta-analysis and meta-regression. BMC Psychiatry 2018; 18:2. [PMID: 29304845 PMCID: PMC5756338 DOI: 10.1186/s12888-017-1580-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 12/14/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The process of assessing the decision-making capacity of potential subjects before their inclusion in clinical trials is a legal requirement and a moral obligation, as it is essential for respecting their autonomy. This issue is especially important in psychiatry patients (such as those diagnosed with schizophrenia). The primary purpose of this article was to evaluate the degree of impairment in each dimension of decision-making capacity in schizophrenia patients compared to non-mentally-ill controls, as quantified by the (MacCAT-CR) instrument. Secondary objectives were (1) to see whether enhanced consent forms are associated with a significant increase in decision-making capacity in schizophrenia patients, and (2) if decision-making capacity in schizophrenia subjects is dependent on the age, gender, or the inpatient status of the subjects. METHODS We systematically reviewed the results obtained from three databases: ISI Web of Science, Pubmed, Scopus. Each database was scrutinised using the following keywords: "MacCAT-CR + schizophrenia", "decision-making capacity + schizophrenia", and "informed consent + schizophrenia." RESULTS We included 13 studies in the analysis. The effect size between the schizophrenia and the control group was significant, with a difference in means of -4.43 (-5.76; -3.1, p < 0.001) for understanding, -1.17 (-1.49, -0.84, p < 0.001) for appreciation, -1.29 (-1.79, -0.79, p < 0.001) for reasoning, and -0.05 (-0.9, -0.01, p = 0.022) for expressing a choice. CONCLUSIONS Even if schizophrenia patients have a significantly decreased decision-making capacity compared to non-mentally-ill controls, they should be considered as competent unless very severe changes are identifiable during clinical examination. Enhanced informed consent forms decrease the differences between schizophrenia patients and non-mentally-ill controls (except for the reasoning dimension) and should be used whenever the investigators want to include more ill patients in their clinical trials. Increased age, men gender and an increased percentage of inpatients might increase the differential of decision-making incompetence compared to non-mentally-ill subjects in various dimensions of the decision-making competence as analysed by the MacCAT-CR scale, but the small number of subjects did not allow us (except for one instance) to reach statistical significance.
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Affiliation(s)
- Sorin Hostiuc
- Carol Davila University of Medicine and Pharmacy, Sos.Vitan Barzesti 9, 042122 Sector 4, Bucuresti, Romania. .,National Institute of Legal Medicine, Bucharest, Romania.
| | - Mugurel Constantin Rusu
- 0000 0000 9828 7548grid.8194.4Carol Davila University of Medicine and Pharmacy, Sos.Vitan Barzesti 9, 042122 Sector 4, Bucuresti, Romania
| | - Ionut Negoi
- 0000 0000 9828 7548grid.8194.4Carol Davila University of Medicine and Pharmacy, Sos.Vitan Barzesti 9, 042122 Sector 4, Bucuresti, Romania
| | - Eduard Drima
- 0000 0004 0571 5814grid.411040.0University of Medicine and Pharmacy, Galați, Romania
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Abstract
CONTEXT Informed consent to research remains a complex issue, while sometimes staying difficult to obtain, even in the general population. This problem may be maximized with patients suffering from schizophrenia. OBJECTIVE This paper summarizes available data in the literature about informed consent for research involving patients suffering from schizophrenia. METHOD Medline and Google Scholar searches were conducted using the following MESH terms: schizophrenia, informed consent and research. RESULTS Studies using dedicated standardized scales (e.g. MacCAT-CR) revealed a decrease in the capacity to consent of patients with schizophrenia when compared with healthy individuals. Keeping in mind that schizophrenia is an heterogeneous disorder, patients with the lowest insight as well as those with the most severe cognitive symptoms appeared more impaired in their capacity to consent. Such a poor capacity to understand and consent to trials was shown linked with alterations in decision-making. For these specific patients, interventions may be set up to increase their capacity to consent. Various strategies were proposed: enhanced consent forms, extended discussion, test/feedback method or multimedia interventions. Among them, interventions relying on communication and the growing field of information technologies (e.g. web-based tools) seem promising. Finally, associations grouping families and patients (like the French Association UNAFAM) may facilitate the involvement of patients in research programs with safer conditions. CONCLUSION Patients suffering from schizophrenia appear able to consent to research programs when suitable interventions are proposed. Further studies are now needed to optimize and individualize such interventions.
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Affiliation(s)
- T Fovet
- Pôle de psychiatrie, université Lille Nord-de-France, hôpital Fontan, CHRU de Lille, rue André-Verhaeghe, 59037 Lille cedex, France.
| | - A Amad
- Pôle de psychiatrie, université Lille Nord-de-France, hôpital Fontan, CHRU de Lille, rue André-Verhaeghe, 59037 Lille cedex, France
| | - P Thomas
- Pôle de psychiatrie, université Lille Nord-de-France, hôpital Fontan, CHRU de Lille, rue André-Verhaeghe, 59037 Lille cedex, France
| | - R Jardri
- Pôle de psychiatrie, université Lille Nord-de-France, hôpital Fontan, CHRU de Lille, rue André-Verhaeghe, 59037 Lille cedex, France
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