Genevra Richardson

Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study

Objective To estimate the prevalence of mental capacity to make decisions on treatment in people from different diagnostic and legal groups admitted to psychiatric hospital. Design Cross sectional study. Setting General adult acute psychiatric inpatient units. Participants 350 consecutive people admitted to psychiatric wards from the community over 16 months. Main outcome measure Mental capacity assessed by clinical interview and the MacArthur competence assessment tool for treatment. Results Estimates of mental capacity were obtained on 97% (n=338) of the 350 people admitted. Of those an estimated 60% (95% confidence interval 55% to 65%) lacked mental capacity to make decisions on treatment. This proportion varied according to diagnosis, ranging from 97% (n=36) in people with mania to 4% (n=24) in people with personality disorder. Mental incapacity was common in patients admitted informally to the psychiatric wards (n=188; 39%, 32% to 46%). Incapacity and detention are closely associated under non-capacity based mental health law. Conclusions Mental incapacity to make decisions on treatment is common in people admitted to psychiatric wards from the community but cannot be presumed. It is usual in those detained under the Mental Health Act and common in those admitted voluntarily.

Mentally disordered or lacking capacity? Lessons for management of serious deliberate self harm

How do you manage a patient who has self harmed but states she doesn’t want life saving treatment? Anthony David and colleagues draw on the case of Kerrie Wooltorton to discuss the difficulties, and in an accompanying article Navneet Kapur and colleagues consider the validity of advance directives

Mental capacity, diagnosis and insight in psychiatric in-patients: a cross-sectional study

BACKGROUND Mental capacity is now a core part of UK mental health law and clinicians will increasingly be expected to assess it. Because it is a legal concept there is a need to clarify associations with variables that clinicians are more familiar with, especially insight. METHOD In this cross-sectional study we recruited consecutive psychiatric admissions to the Maudsley Hospital, London. We carried out structured assessments of decision making using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), resulting in a clinical judgement about capacity status. We analysed associations with a range of sociodemographic and clinical variables, including insight score on the Expanded Schedule for the Assessment of Insight (SAI-E). The same variables were compared in an analysis stratified according to diagnostic group: psychotic disorders/bipolar affective disorder (BPAD)/non-psychotic disorders. RESULTS Psychotic disorders and manic episodes of BPAD are most strongly associated with incapacity. In such patients, insight is the best discriminator of capacity status. In patients with non-psychotic disorders, insight is less strongly associated with capacity; in this group depressed mood discriminates capacity status whereas it does not in psychotic disorders. Cognitive performance does not discriminate capacity status in patients with psychotic disorders. CONCLUSIONS Mental capacity has complex relationships with psychopathological variables, and these relationships are different according to diagnostic group. Insight is the best discriminator of capacity status in psychotic disorders and BPAD but not in non-psychotic disorders.

Mental Capacity and Decisional Autonomy: An Interdisciplinary Challenge

With the waves of reform occurring in mental health legislation in England and other jurisdictions, mental capacity is set to become a key medico‐legal concept. The concept is central to the law of informed consent and is closely aligned to the philosophical concept of autonomy. It is also closely related to mental disorder. This paper explores the interdisciplinary terrain where mental capacity is located. Our aim is to identify core dilemmas and to suggest pathways for future interdisciplinary research. The terrain can be separated into three types of discussion: philosophical, legal and psychiatric. Each discussion approaches mental capacity and judgmental autonomy from a different perspective yet each discussion struggles over two key dilemmas: whether mental capacity and autonomy is/should be a moral or a psychological notion and whether rationality is the key constitutive factor. We suggest that further theoretical work will have to be interdisciplinary and that this work offers an opportunity for the law to enrich its interpretation of mental capacity, for psychiatry to clarify the normative elements latent in its concepts and for philosophy to advance understanding of autonomy through the study of decisional dysfunction. The new pressures on medical and legal practice to be more explicit about mental capacity make this work a priority.

Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study

Background Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients? Aims To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice. Method A secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool - Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability. Results Most people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P = 0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better ‘test’ of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P = 0.02). Conclusions Among those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting.

Retrospective views of psychiatric in-patients regaining mental capacity

Background An individual’s right to self-determination in treatment decisions is a central principle of modern medical ethics and law, and is upheld except under conditions of mental incapacity. When doctors, particularly psychiatrists, override the treatment wishes of individuals, they risk conflicting with this principle. Few data are available on the views of people regaining capacity who had their treatment wishes overridden. Aims To investigate individuals’ views on treatment decisions after they had regained capacity. Method One hundred and fifteen people who lacked capacity to make treatment decisions were recruited from a sample of consecutively admitted patients to a large psychiatric hospital. After 1 month of treatment we asked the individuals for their views on the surrogate treatment decisions they received. Results Eighty-three per cent (95% CI 66–93) of people who regained capacity gave retrospective approval. Approval was no different between those admitted informally or involuntarily using Mental Health Act powers (χ2 = 1.52, P = 0.47). Individuals were more likely to give retrospective approval if they regained capacity (χ2 = 14.2, P = 0.001). Conclusions Most people who regain capacity following psychiatric treatment indicate retrospective approval. This is the case even if initial treatment wishes are overridden. These findings moderate concerns both about surrogate decision-making by psychiatrists and advance decision-making by people with mental illness.

Mental capacity and psychiatric in-patients: implications for the new mental health law in England and Wales

Background In England and Wales mental health services need to take account of the Mental Capacity Act 2005 and the Mental Health Act 1983. The overlap between these two causes dilemmas for clinicians. Aims To describe the frequency and characteristics of patients who fall into two potentially anomalous groups: those who are not detained but lack mental capacity; and those who are detained but have mental capacity. Method Cross-sectional study of 200 patients admitted to psychiatric wards. We assessed mental capacity using a semi-structured interview, the MacArthur Competence Assessment Tool for Treatment (MacCAT–T). Results Of the in-patient sample, 24% were informal but lacked capacity: these patients felt more coerced and had greater levels of treatment refusal than informal participants with capacity. People detained under the Mental Health Act with capacity comprised a small group (6%) that was hard to characterise. Conclusions Our data suggest that psychiatrists in England and Wales need to take account of the Mental Capacity Act, and in particular best interests judgments and deprivation of liberty safeguards, more explicitly than is perhaps currently the case.

Autonomy, Guardianship and Mental Disorder: One Problem, Two Solutions

The law in England and Wales governing both the provision of medical care in the case of adults with incapacity and the provision of care and treatment for mental disorder presents serious problems for the principle of patient autonomy. The adult with incapacity has no competence either to consent to or refuse medical treatment but the law provides no statutory structure for substitute decision making on that adults behalf. On the other hand the law does allow a person with mental disorder to be treated for that disorder despite his or her competent refusal. The nature of these inconsistencies is considered and the implications which flow from the singling out of mental disorder are examined with reference to experience in two Australian jurisdictions. The current proposals for reform of the Mental Health Act are then considered in the light of the conclusions drawn.

Mental capacity at the margin: the interface between two acts.

Developed legal systems commonly provide special powers to intervene in the medical care and treatment of people with mental disorder. Typically, this intervention will take the form of involuntary hospitalisation and treatment, and the law is used to specify the point at which otherwise unlawful interference or coercion becomes lawful. However, by making an exception of mental disorder and providing special powers of intervention in relation to it, the law has not only to specify the nature and limits of those powers, but it must also identify the population to whom they apply—people with mental disorder. This question of demarcation can cause difficulties and uncertainties at the interface between mental disorder and physical disorder, for example, or between mental disorder and deviance, or between mental disorder and mental incapacity. While the interface between mental disorder and deviance or anti-social behaviour has proved notoriously problematic over the years and will no doubt continue to do so, it is the interface between mental disorder and mental incapacity that is currently causing most practical concern in England and Wales. And it is with this interface that the present article is primarily concerned. The Mental Health Act 1983 (MHA) establishes a framework for the provision of medical treatment, on an involuntary basis if necessary, for those suffering from mental disorder to the necessary degree. The main criteria for its application are the presence of mental disorder and risk to the patient or to others. The Mental Capacity Act 2005 (MCA) provides

Mental capacity in the shadow of suicide: What can the law do?

In a society where suicide is lawful how should we respond to a life-threatening treatment refusal by someone whose decision-making might be affected by a mental disorder? In considering this question this article examines the three established concepts currently employed by the law to analyse such cases: mental capacity, best interests and mental disorder. It then considers whether a supported decision-making model based on a notion of universal capacity, such as that espoused by the Convention on the Rights of Persons with Disabilities, might alleviate some of the dilemmas arising from the application of the traditional legal concepts.