Hostname: page-component-76fb5796d-x4r87 Total loading time: 0 Render date: 2024-04-28T13:31:52.231Z Has data issue: false hasContentIssue false
  • English
  • Français

Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis

Published online by Cambridge University Press:  04 March 2024

Silvia Marcó-García Open the ORCID record for Silvia Marcó-García [Opens in a new window] ,
Kevin Ariyo ,
Gareth S. Owen  and
Anthony S. David
Silvia Marcó-García*
Affiliation:
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
Affiliation:
Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
Gareth S. Owen
Affiliation:
Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
Anthony S. David
Affiliation:
Division of Psychiatry, UCL Institute of Mental Health, University College London, London, UK
*
Corresponding author: Silvia Marcó-García; Email: silvia.marco@sjd.es
Get access Rights & Permissions [Opens in a new window]

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.

Keywords

assessmentmental capacitymetaanalysispsychiatric inpatientssevere mental disordertreatment
Type
Review Article
Information
Psychological Medicine , Volume 54 , Issue 6 , April 2024 , pp. 1074 - 1083
Check for updates
Copyright
Copyright © The Author(s), 2024. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Aberson, C., Rodriguez, J. E., & Siegel, D. (2022). Power Analysis for Regression Coefficients: The Role of Multiple Predictors and Power to Detect all Coefficients simultaneously. OSF Preprints, 0–3. https://doi.org/10.31219/osf.io/m9ev5CrossRefGoogle Scholar
Ariyo, K., McWilliams, A., David, A. S., & Owen, G. S. (2021). Experiences of assessing mental capacity in England and Wales: A large-scale survey of professionals. Wellcome Open Research, 6, 144. https://doi.org/10.12688/WELLCOMEOPENRES.16823.1CrossRefGoogle Scholar
Banner, N. F. (2012). Unreasonable reasons: Normative judgements in the assessment of mental capacity. Journal of Evaluation in Clinical Practice, 18(5), 1038–1044. https://doi.org/10.1111/J.1365-2753.2012.01914.XCrossRefGoogle ScholarPubMed
Barrios Flores, L. F. (2020). [Law and mental health (goals achieved and pending challenges in Spain). SESPAS report 2020]. Gaceta Sanitaria 34(Suppl. 1), 76–80. https://doi.org/10.1016/J.GACETA.2020.04.011CrossRefGoogle ScholarPubMed
Bilanakis, N., Vratsista, A., Kalampokis, G., Papamichael, G., & Peritogiannis, V. (2013). The Greek version of the MacArthur competence assessment tool for treatment: Reliability and validity. Evaluation of capacity for treatment decisions in Greek psychiatric patients. Annals of General Psychiatry, 12(1), 10. https://doi.org/10.1186/1744-859X-12-10CrossRefGoogle ScholarPubMed
Breden, T. M., & Vollmann, J. (2004). The cognitive based approach of capacity assessment in psychiatry: A philosophical critique of the MacCAT-T. Health Care Analysis: HCA: Journal of Health Philosophy and Policy, 12(4), 273–283. https://doi.org/10.1007/S10728-004-6635-XCrossRefGoogle ScholarPubMed
Cáceda, R., Nemeroff, C. B., & Harvey, P. D. (2014). Toward an understanding of decision making in severe mental illness. The Journal of Neuropsychiatry and Clinical Neurosciences, 26(3), 196–213. https://doi.org/10.1176/APPI.NEUROPSYCH.12110268CrossRefGoogle ScholarPubMed
Cairns, R., Maddock, C., Buchanan, A., David, A. S., Hayward, P., Richardson, G., … Hotopf, M. (2005). Reliability of mental capacity assessments in psychiatric in-patients. The British Journal of Psychiatry, 187(4), 372–378. https://doi.org/10.1192/BJP.187.4.372CrossRefGoogle ScholarPubMed
Calcedo-Barba, A., Fructuoso, A., Martinez-Raga, J., Paz, S., Sánchez De Carmona, M., & Vicens, E. (2020). A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare. BMC Psychiatry, 20(1), 339. https://doi.org/10.1186/S12888-020-02756-0CrossRefGoogle ScholarPubMed
Chiu, N. M., Lee, Y., & Lee, W. K. (2014). Electroconvulsive therapy without consent from patients: One-year follow-up study. Asia-Pacific Psychiatry, 6(1), 83–90. https://doi.org/10.1111/J.1758-5872.2012.00203.XCrossRefGoogle ScholarPubMed
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. In Statistical power analysis for the behavioral sciences (2nd ed., 567 pages). New York: Routledge. https://doi.org/10.4324/9780203771587Google Scholar
Cooper, H., & Patall, E. A. (2009). The relative benefits of meta-analysis conducted with individual participant data versus aggregated data. Psychological Methods, 14(2), 165–176. https://doi.org/10.1037/A0015565CrossRefGoogle ScholarPubMed
Curley, A., Murphy, R., Fleming, S., & Kelly, B. D. (2019a). Age, psychiatry admission status and linear mental capacity for treatment decisions. International Journal of Law and Psychiatry, 66, 101469. https://doi.org/10.1016/J.IJLP.2019.101469CrossRefGoogle ScholarPubMed
Curley, A., Murphy, R., Plunkett, R., & Kelly, B. D. (2019b). Categorical mental capacity for treatment decisions among psychiatry inpatients in Ireland. International Journal of Law and Psychiatry, 64, 53–59. https://doi.org/10.1016/J.IJLP.2019.02.001CrossRefGoogle ScholarPubMed
Curley, A., Murphy, R., Plunkett, R., & Kelly, B. D. (2019c). Concordance of mental capacity assessments based on legal and clinical criteria: A cross-sectional study of psychiatry inpatients. Psychiatry Research, 276, 160–166. https://doi.org/10.1016/J.PSYCHRES.2019.05.015CrossRefGoogle ScholarPubMed
Curley, A., Watson, C., & Kelly, B. D. (2021). Capacity to consent to treatment in psychiatry inpatients - a systematic review. International Journal of Psychiatry in Clinical Practice, 26(3), 303–315. https://doi.org/10.1080/13651501.2021.2017461CrossRefGoogle ScholarPubMed
Di, X., & Cheng, H. G. (2013). Competence of consent and associated factors among inpatients of schizophrenia in Changsha, China. Schizophrenia Research, 150(1), 325–326. https://doi.org/10.1016/J.SCHRES.2013.07.041CrossRefGoogle ScholarPubMed
Dornan, J., Kennedy, M., Garland, J., Rutledge, E., & Kennedy, H. G. (2015). Functional mental capacity, treatment as usual and time: Magnitude of change in secure hospital patients with major mental illness. BMC Research Notes, 8, 566. https://doi.org/10.1186/s13104-015-1547-4CrossRefGoogle ScholarPubMed
Dunn, L. B., Palmer, B. W., Appelbaum, P. S., Saks, E. R., Aarons, G. A., & Jeste, D. V. (2007). Prevalence and correlates of adequate performance on a measure of abilities related to decisional capacity: Differences among three standards for the MacCAT-CR in patients with schizophrenia. Schizophrenia Research, 89(1–3), 110–118. https://doi.org/10.1016/J.SCHRES.2006.08.005CrossRefGoogle ScholarPubMed
Fraguas, D., García-Solano, F., Chapela, E., Terán, S., de la Peña, J. J., & Calcedo-Barba, A. (2007). Do psychiatric patients improve their competency to consent to hospitalization after admission? A prospective study in an acute inpatient ward. General Hospital Psychiatry, 29(1), 54–62. https://doi.org/10.1016/J.GENHOSPPSYCH.2006.09.005CrossRefGoogle Scholar
Ioannidis, J. P. A. (2008). Interpretation of tests of heterogeneity and bias in meta-analysis. Journal of Evaluation in Clinical Practice, 14(5), 951–957. https://doi.org/10.1111/J.1365-2753.2008.00986.XCrossRefGoogle ScholarPubMed
Jacob, R., Clare, I. C. H., Holland, A., Watson, P. C., Maimaris, C., & Dunn, M. (2005). Self-harm, capacity, and refusal of treatment: Implications for emergency medical practice. A prospective observational study. Emergency Medicine Journal: EMJ, 22(11), 799. https://doi.org/10.1136/EMJ.2004.018671CrossRefGoogle ScholarPubMed
John, S., Rowley, J., & Bartlett, K. (2020). Assessing patients decision-making capacity in the hospital setting: A literature review. The Australian Journal of Rural Health, 28(2), 141–148. https://doi.org/10.1111/AJR.12592CrossRefGoogle ScholarPubMed
Kahn, D. R., Bourgeois, J. A., Klein, S. C., & Ana-maria Losif, C. (2009). A prospective observational study of decisional capacity determinations in an academic medical center. The International Journal of Psychiatry in Medicine, 39(4), 405–415. https://doi.org/10.2190/PM.39.4.eCrossRefGoogle Scholar
Kennedy, M., Dornan, J., Rutledge, E., O'Neill, H., & Kennedy, H. G. (2009). Extra information about treatment is too much for the patient with psychosis. International Journal of Law and Psychiatry, 32(6), 369–376. https://doi.org/10.1016/J.IJLP.2009.09.006CrossRefGoogle ScholarPubMed
Kmet, L. M., Lee, R. C., & Cook, L. S. (2004) Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. Alberta Heritage Foundation for Medical Research, 13, 31 p. https://www.ihe.ca/advanced-search/standard-quality-assessment-criteria-for-evaluating-primary-research-papers-from-a-variety-of-fieldsGoogle Scholar
Lamont, S., Stewart, C., & Chiarella, M. (2016). Decision-making capacity and its relationship to a legally valid consent: Ethical, legal and professional context. Journal of Law and Medicine, 24(2), 371–386.Google ScholarPubMed
Larkin, A., & Hutton, P. (2017). Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis. The British Journal of Psychiatry: The Journal of Mental Science, 211(4), 205–215. https://doi.org/10.1192/BJP.BP.116.193458CrossRefGoogle ScholarPubMed
Lepping, P., Stanly, T., & Turner, J. (2015). Systematic review on the prevalence of lack of capacity in medical and psychiatric settings. Clinical Medicine (London, England), 15(4), 337–343. https://doi.org/10.7861/CLINMEDICINE.15-4-337CrossRefGoogle ScholarPubMed
Luo, D., Wan, X., Liu, J., & Tong, T. (2018). Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Statistical Methods in Medical Research, 27(6), 1785–1805. https://doi.org/10.1177/0962280216669183CrossRefGoogle ScholarPubMed
Ma, J., Liu, W., Hunter, A., & Zhang, W. (2008). Performing meta-analysis with incomplete statistical information in clinical trials. BMC Medical Research Methodology, 8, 56. https://doi.org/10.1186/1471-2288-8-56CrossRefGoogle ScholarPubMed
Mandarelli, G., Carabellese, F., Parmigiani, G., Bernardini, F., Pauselli, L., Quartesan, R., … Ferracuti, S. (2018). Treatment decision-making capacity in non-consensual psychiatric treatment: A multicentre study. Epidemiology and Psychiatric Sciences, 27(5), 492–499. https://doi.org/10.1017/S2045796017000063CrossRefGoogle ScholarPubMed
Mandarelli, G., Parmigiani, G., Tarsitani, L., Frati, P., Biondi, M., & Ferracuti, S. (2012). The relationship between executive functions and capacity to consent to treatment in acute psychiatric hospitalization. Journal of Empirical Research on Human Research Ethics: JERHRE, 7(5), 63–70. https://doi.org/10.1525/jer.2012.7.5.63CrossRefGoogle ScholarPubMed
Mandarelli, G., Tarsitani, L., Parmigiani, G., Polselli, G. M., Frati, P., Biondi, M., & Ferracuti, S. (2014). Mental capacity in patients involuntarily or voluntarily receiving psychiatric treatment for an acute mental disorder. Journal of Forensic Sciences, 59(4), 1002–1007. https://doi.org/10.1111/1556-4029.12420CrossRefGoogle ScholarPubMed
Maxmin, K., Cooper, C., Potter, L., & Livingston, G. (2009). Mental capacity to consent to treatment and admission decisions in older adult psychiatric inpatients. International Journal of Geriatric Psychiatry, 24(12), 1367–1375. https://doi.org/10.1002/GPS.2272CrossRefGoogle ScholarPubMed
McHugh, M. L. (2012). Interrater reliability: The kappa statistic. Biochemia Medica, 22(3), 276. https://doi.org/10.11613/bm.2012.031CrossRefGoogle ScholarPubMed
Moye, J., Karel, M. J., Edelstein, B., Hicken, B., Armesto, J. C., & Gurrera, R. J. (2007). Assessment of capacity to consent to treatment: Challenges, the “ACCT” approach, future directions. Clinical Gerontologist, 31(3), 37. https://doi.org/10.1080/07317110802072140CrossRefGoogle ScholarPubMed
Murri, M. B., Amore, M., Calcagno, P., Respino, M., Marozzi, V., Masotti, M., … Maj, M. (2016). The “insight paradox” in schizophrenia: Magnitude, moderators and mediators of the association between insight and depression. Schizophrenia Bulletin, 42(5), 1225. https://doi.org/10.1093/SCHBUL/SBW040CrossRefGoogle Scholar
Okai, D., Owen, G., McGuire, H., Singh, S., Churchill, R., & Hotopf, M. (2007). Mental capacity in psychiatric patients: Systematic review. The British Journal of Psychiatry: The Journal of Mental Science, 191(6), 5–10. https://doi.org/10.1192/BJP.BP.106.035162CrossRefGoogle ScholarPubMed
Ouzzani, M., Hammady, H., Fedorowicz, Z., & Elmagarmid, A. (2016). Rayyan-a web and mobile app for systematic reviews. Systematic Reviews, 5(1), 1–10. https://doi.org/10.1186/S13643-016-0384-4/FIGURES/6CrossRefGoogle ScholarPubMed
Owen, G., David, A. S., Richardon, G., Szmukler, G., Hayward, P., & Hotopf, M. (2009). Mental capacity, diagnosis and insight in psychiatric in-patients: A cross-sectional study. Psychological Medicine, 39(8), 1389–1398. https://doi.org/10.1017/S0033291708004637CrossRefGoogle ScholarPubMed
Owen, G. S., Richardson, G., David, A. S., Szmukler, G., Hayward, P., & Hotopf, M. (2008). Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: Cross sectional study. BMJ (Clinical Research Ed.), 337(7660), a448. https://doi.org/10.1136/BMJ.39580.546597.BECrossRefGoogle ScholarPubMed
Owen, G. S., Ster, I. C., David, A. S., Szmukler, G., Hayward, P., Richardson, G., & Hotopf, M. (2011). Regaining mental capacity for treatment decisions following psychiatric admission: A clinico-ethical study. Psychological Medicine, 41(1), 119–128. https://doi.org/10.1017/S0033291710000383CrossRefGoogle ScholarPubMed
Parabiaghi, A., Bonetto, C., Ruggeri, M., Lasalvia, A., & Leese, M. (2006). Severe and persistent mental illness: a useful definition for prioritizing community-based mental health service interventions. Social Psychiatry and Psychiatric Epidemiology, 41(6), 457–463. https://doi.org/10.1007/s00127-006-0048-0CrossRefGoogle ScholarPubMed
Pons, E. V., Salvador-Carulla, L., Calcedo-Barba, A., Paz, S., Messer, T., Pacciardi, B., & Zeller, S. L. (2020). 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 Science Reports, 3(3), e179. https://doi.org/10.1002/HSR2.179CrossRefGoogle ScholarPubMed
Raymont, V., Buchanan, A., David, A. S., Hayward, P., Wessely, S., & Hotopf, M. (2007). The inter-rater reliability of mental capacity assessments. International Journal of Law and Psychiatry, 30(2), 112. https://doi.org/10.1016/J.IJLP.2005.09.006CrossRefGoogle ScholarPubMed
Riley, R. D., Lambert, P. C., & Abo-Zaid, G. (2010). Meta-analysis of individual participant data: Rationale, conduct, and reporting. BMJ (Clinical Research Ed, 340(7745), 521–525. https://doi.org/10.1136/BMJ.C221CrossRefGoogle ScholarPubMed
Ruck Keene, A., Kane, N. B., Kim, S. Y. H., & Owen, G. S. (2023). Mental capacity-why look for a paradigm shift? Medical Law Review, 31(3), 340–357. https://doi.org/10.1093/MEDLAW/FWAC052CrossRefGoogle ScholarPubMed
Rutledge, E., Kennedy, M., O'Neill, H., & Kennedy, H. G. (2008). Functional mental capacity is not independent of the severity of psychosis. International Journal of Law and Psychiatry, 31(1), 9–18. https://doi.org/10.1016/J.IJLP.2007.11.002CrossRefGoogle Scholar
Ryba, N. L., & Zapf, P. A. (2011). The influence of psychiatric symptoms and cognitive abilities on competence-related abilities. The International Journal of Forensic Mental Health, 10(1), 29–40. https://doi.org/10.1080/14999013.2010.550982CrossRefGoogle Scholar
Seo, M. K., Kim, S. H., & Rhee, M. (2011). Developing a tool to Assess Competency to Consent to Psychiatric Hospitalization (KATOC): Reliability and Validity. Psychiatry Investigation, 8(1), 39–48. https://doi.org/10.4306/pi.2011.8.1.39CrossRefGoogle ScholarPubMed
Seo, M. K., Kim, S. H., Rhee, M., S, M. K., K, S. H., & R, M. (2011). Developing a tool to assess competency to consent to psychiatric hospitalization (KATOC): Reliability and validity. Psychiatry Investigation, 8(1), 39–48. https://doi.org/10.4306/PI.2011.8.1.39CrossRefGoogle ScholarPubMed
Series, L. (2020). Comment: Mental capacity (amendment) Act 2019 (UK). Elder Law Review (Penrith South, N.S.W.), 12(1), 0006.Google ScholarPubMed
Skipworth, J. J., Dawson, J., & Ellis, P. M. (2013). Capacity of forensic patients to consent to treatment. The Australian and New Zealand Journal of Psychiatry, 47(5), 443–450. https://doi.org/10.1177/0004867412468495CrossRefGoogle ScholarPubMed
Spencer, B. W. J., Gergel, T., Hotopf, M., & Owen, G. S. (2018). Unwell in hospital but not incapable: Cross-sectional study on the dissociation of decision-making capacity for treatment and research in in-patients with schizophrenia and related psychoses. The British Journal of Psychiatry: The Journal of Mental Science, 213(2), 484–489. https://doi.org/10.1192/BJP.2018.85CrossRefGoogle Scholar
Spencer, B. W. J., Shields, G., Gergel, T., Hotopf, M., & Owen, G. S. (2017). Diversity or disarray? A systematic review of decision-making capacity for treatment and research in schizophrenia and other non-affective psychoses. Psychological Medicine, 47(11), 1906–1922. https://doi.org/10.1017/S0033291717000502CrossRefGoogle ScholarPubMed
Stefanopoulou, E., Lafuente, A. R., Saez Fonseca, J. A., & Huxley, A. (2009). Insight, global functioning and psychopathology amongst in-patient clients with schizophrenia. The Psychiatric Quarterly, 80(3), 155–165. https://doi.org/10.1007/S11126-009-9103-9CrossRefGoogle ScholarPubMed
Testa, R., & Pantelis, C. (2009). The role of executive functions in psychiatric disorders. In Wood, S. J., Allen, N. B., & Pantelis, C. (Eds.), The neuropsychology of mental illness (pp. 117–137). Cambridge University Press. https://doi.org/10.1017/CBO9780511642197.012CrossRefGoogle Scholar
Tor, P. C., Tan, F. J. S., Martin, D., & Loo, C. (2020). Outcomes in patients with and without capacity in electroconvulsive therapy. Journal of Affective Disorders, 266, 151–157. https://doi.org/10.1016/J.JAD.2020.01.150CrossRefGoogle ScholarPubMed
United Nations. (2006). Convention on the Rights of Persons with Disabilities. Treaty Series, vol. 2515, Dec. 2006. A/RES/61/106 https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-persons-disabilitiesGoogle Scholar
van der Plas, E., David, A. S., & Fleming, S. M. (2019). Advice-taking as a bridge between decision neuroscience and mental capacity. International Journal of Law and Psychiatry, 67, 101504. https://doi.org/10.1016/J.IJLP.2019.101504CrossRefGoogle ScholarPubMed
Wan, X., Wang, W., Liu, J., & Tong, T. (2014). Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Medical Research Methodology, 14(1), 1–13. https://doi.org/10.1186/1471-2288-14-135/TABLES/3CrossRefGoogle ScholarPubMed
Wang, S. B., Wang, Y. Y., Ungvari, G. S., Ng, C. H., Wu, R. R., Wang, J., & Xiang, Y. T. (2017). The MacArthur competence assessment tools for assessing decision-making capacity in schizophrenia: A meta-analysis. Schizophrenia Research, 183, 56–63. https://doi.org/10.1016/J.SCHRES.2016.11.020CrossRefGoogle ScholarPubMed
Yaple, Z. A., Tolomeo, S., & Yu, R. (2021). Mapping working memory-specific dysfunction using a transdiagnostic approach. NeuroImage: Clinical, 31, 102747. https://doi.org/10.1016/J.NICL.2021.102747CrossRefGoogle ScholarPubMed
Supplementary material: File

Marcó-García et al. supplementary material 1

Marcó-García et al. supplementary material
Download Marcó-García et al. supplementary material 1(File)
File 26 KB
Supplementary material: File

Marcó-García et al. supplementary material 2

Marcó-García et al. supplementary material
Download Marcó-García et al. supplementary material 2(File)
File 205.1 KB