Institute of Psychiatry, London
Department of Psychiatry, Yale University, New Haven, Connecticut, USA
Institute of Psychiatry, London
Institute of Psychiatry/Maudsley Hospital, London
Queen Mary College, University of London
Institute of Psychiatry, London, UK
Correspondence: Professor Matthew Hotopf, Academic Department of Psychological Medicine, Institute of Psychiatry, Weston Education Centre, 10 Cutcombe Road, London SE5 9RJ, UK. Tel: +44(0)2078480778; fax: ++44(0)2078485408; e-mail: m.hotopf{at}iop.kcl.ac.uk
Declaration of interest None. The study was funded by the Wellcome Trust.
See pp.
372378, this issue.
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ABSTRACT |
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Aims To determine the prevalence of psychiatric in-patients who lack capacity to make decisions about current treatment and to identify demographic and clinical associations with lackof mental capacity.
Method Patients (n=112) were interviewed soon after admission to hospital and a binaryjudgement of capacity was made, guided by the MacArthur Competence Tool for Treatment. Demographic and clinical information was collected from an interview and case notes.
Results Of the 112 participants, 49 (43.8%) lacked treatment-related decisional capacity. Mania and psychosis, poor insight, delusions and Black and minority ethnic group were associated with mentalincapacity. Of the 49 patients lacking capacity, 30 (61%) were detained under the Mental Health Act 1983. Of the 63 with capacity, 6 (9.5%) were detained.
Conclusions Lack of treatment-related decisional capacity is a common but by no means inevitable correlate of admission to a psychiatric in-patient unit.
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INTRODUCTION |
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METHOD |
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Measurement of capacity
The MacArthur Competence Assessment Tool for Treatment (MacCATT) was
administered to each patient (Grisso
et al, 1997). It is a semi-structured interview that
provides relevant treatment information for the patient and evaluates capacity
in terms of its different components. As such it can detect impairment in four
areas: the patients understanding of the disorder and
treatment-related information; appreciation of the significance of
that information for the patient; the reasoning ability of the
patient to compare their prescribed medication with an alternative treatment;
and ability of the patient to express a choice between their
recommended medication and an alternative treatment. The interview was
modified slightly for our study and patients were given the option of
no treatment as the alternative to their prescribed or
recommended medication. This was to avoid confusion about the
patients current treatment and also to prevent potential problems in
the relationship between the participant and the treating clinician.
Before each interview, relevant information about the patients diagnosis, presenting symptoms and recommended treatment was obtained from the case notes and discussion with the clinical team. Where a patient was on more than one psychotropic medication, the interview focused on the medication that was judged to be the patients main treatment. This information was disclosed to the patient during the MacCATT interview together with standardised information about the features, benefits and risks of the recommended treatment (based on UK Psychiatric Pharmacy Group Information leaflets; http://www.ukppg.org.uk) and of the no treatment option. After each interview the interviewer scored understanding, appreciation, reasoning and expression of choice according to MacCATT criteria and made a global judgement about the patients capacity to make a treatment decision, based on information from both the MacCATT and a clinical interview with the patient. We used the England and Wales Draft Mental Incapacity Bill (Department for Constitutional Affairs, 2003) definition of mental incapacity in order to reach a binary (yes/no) decision.
Fifty-five patients in the present study were recruited initially for a study investigating the interrater reliability of capacity assessments (Cairns et al, 2005, this issue). These patients had been interviewed on two occasions by two separate interviewers and an excellent level of agreement for global capacity judgements was demonstrated for two separate interviews (kappa=0.82) and for the same interview, based on transcripts. One of the interviewers (R.C.) from the initial study continued to recruit patients for this study and therefore data she had collected from the first 55 patients were used for this study in preference to the data collected by the other interviewer. For the 57 cases seen only for this study, a consensus judgement was reached between the interviewer and a psychiatrist (M.H.) with an interest in mental capacity, when the judgement was felt to be difficult. In practice this amounted to eight interviews.
Other measures
Demographic and clinical information about each participant was collected
from the case notes. In addition to the MacCATT, the Brief Psychiatric
Rating Scale (BPRS) (Ventura et
al, 1993), the Expanded Schedule for Assessment of Insight
(SAIE) (Kemp & David,
1997; Sanz et al,
1998), the Mini Mental State Examination (MMSE)
(Folstein et al,
1975) and the Brief Perceived Coercion Scale (BPCS)
(Gardner et al, 1993)
were completed for each patient. It was also noted whether the patient was
documented as having delusional beliefs or experiencing auditory
hallucinations at the time of admission.
The SAIE is a semi-structured interview that measures three dimensions of insight (treatment compliance, recognition of illness, and relabelling of psychotic phenomena), as well as awareness of changes in mental functioning, of the need for treatment and of the psychosocial consequences of illness. It also includes a question on response to hypothetical contradiction. The BPCS is a sub-scale from the MacArthur Admission Experience Survey, Short Form, and asks patients to judge the degree of influence, control, choice and freedom they had about their admission to hospital.
Statistical analyses
Data analysis was performed using the Statistical Package for Social
Sciences Version 11 (SPSS,
2001) and STATA (release 8.0;
Stata Corporation, 2003). The
prevalence figure for mental incapacity was calculated with 95% confidence
intervals. Conventional bivariate methods were used to compare patients who
were judged to lack capacity with those who were judged to have capacity.
Logistic regression analysis was then performed to identify independent
associations for incapacity. Each logistic regression model forced independent
variables into a model in order to test specific hypotheses.
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RESULTS |
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The interviewed group comprised 71 men and 41 women with a mean age of 37.2 years (s.d.=11.8). They were interviewed, on average, 3.3 days after admission. Diagnoses were made according to ICD10 criteria (World Health Organization, 1993) by the treating clinical team and 62 participants (55.4%) had the following psychotic illnesses: schizophrenia (37), schizoaffective disorder (11) and other psychotic disorder (14). Twenty-one participants (18.8%) had a diagnosis of bipolar affective disorder, 25 (22.3%) had a diagnosis of depression and 4 (3.6%) had emotionally unstable personality disorder, borderline type. Thirty-six participants (32.1%) had been admitted under the Mental Health Act 1983 and the remaining 76 were voluntary.
The interviewed group differed from the non-participants in terms of admission status, with higher proportions of the latter detained under the Mental Health Act 1983. A higher proportion of men agreed to take part than women and there were also differences in the distribution of psychiatric diagnoses between participants and non-participants. A comparison of the two groups is shown in Table 1.
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Ratings and predictors of incapacity
Of the participants, 49 (43.8%) (95% CI 34.654.0) lacked
treatment-related decisional capacity, based on a judgement guided by the
MacCATT and a clinical interview. The binary rating of capacity was
based on the definition of inability to make decisions proposed
in the Draft Mental Incapacity Bill (England and Wales)
(Department for Constitutional Affairs,
2003) (now the Mental Capacity Act 2005).
The socio-demographic and clinical characteristics of participants with and without mental capacity are shown in Table 2. Those lacking capacity were more likely to have a psychotic illness or bipolar affective disorder and to be Black African or AfricanCaribbean. They were also more likely to be detained under the Mental Health Act 1983, to experience delusions, to have higher scores on the BPRS and BPCS and to score significantly less on the MMSE and SAIE. There were no statistically significant differences between the groups in terms of age, gender, educational level, marital status, employment status, number of previous admissions or whether the individuals experienced auditory hallucinations.
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Multivariable analyses
Because there was an apparent association (P=0.08) between Black
and minority ethnic group and lack of capacity, we first explored whether this
could be explained by diagnosis and/or country of birth (i.e. whether or not
UK-born) using logistic regression analysis. The odds ratio for incapacity for
all Black and minority ethnic groups as a single category was 2.36 (95% CI
1.105.05), but this became considerably smaller once diagnosis was
controlled for (OR=1.59, 95% CI 0.683.68), and was eradicated when
country of birth and diagnosis were controlled for simultaneously (OR=1.11,
95% CI 0.413.04). When different ethnic groups were considered, the
overall significance of the effect was P=0.07 but this masked a
strong, if imprecise, association between AfricanCaribbean ethnic group
and lack of mental capacity (OR=9.75, 95% CI 1.0789.2). This was
reduced, although not eradicated, by controlling for diagnosis (OR=5.81, 95%
CI 0.6155.4). Country of birth was not controlled for in this analysis
because of the large overlap in country of birth and ethnic group
variables.
A second set of logistic regression analyses explored clinical variables. As there was considerable overlap between clinical variables (diagnosis, psychopathology such as experience of hallucinations and delusions, and scores on specific measures), we entered these variables into a logistic regression analysis shown in Table 3. In the first model, we entered diagnosis, presence of delusions, BPRS score and MMSE score. This model concentrated on the severity and type of psychopathology. Two variables were associated with incapacity diagnosis (particularly mania or hypomania) and the presence of delusions. In the second model, which comprised diagnosis, presence of delusions, insight, perceived coercion, use of the Mental Health Act 1983, MMSE and BPRS scores, the only association which was statistically significant was insight. Those having higher insight scores were less likely to be rated as lacking capacity. There was a slighter non-significant association with MMSE, with those scoring higher being less likely to lack capacity. No other clinical variable was associated.
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Out of the 63 patients who had capacity to make a treatment decision, 57
were admitted to hospital on a voluntary basis but 6 were detained under the
Mental Health Act 1983. The only significant demographic or clinical
differences between these two groups were that the detained patients had
higher perceived coercion scores and the voluntarily admitted patients had
unexpectedly higher scores of psychopathology on the BPRS. A comparison of
these groups is shown in Table
4. Perceived coercion was also higher among patients who lacked
mental capacity but were detained (mean score in those detained=4.0, s.d.=1.23
v. mean score for those not detained=2.4, s.d.=1.5;
2=13.6; d.f.=5; P=0.02).
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DISCUSSION |
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Factors associated with lack of capacity
The majority of patients (45 out of 49) who were judged incapable of making
a treatment decision suffered from either a psychotic illness or bipolar
affective disorder. We did not use a semi-structured diagnostic interview, and
deliberately describe broad clinically derived diagnostic categories. The
association was confirmed in regression analyses showing that mania and
hypomania in particular were closely associated with incapacity, as was the
experience of delusional beliefs. A similar pattern was described by Bellhouse
et al (2003) where all
participants lacking capacity had a psychotic illness, although the authors
made the important point that psychosis is not invariably associated with
incapacity (six out of nine participants with schizophrenia had capacity to
consent to treatment).
We found that Black and minority ethnic group was associated with lack of capacity, particularly in AfricanCaribbean participants. The effect of ethnicity may be due to several factors most important being diagnosis. Very few (9%) individuals from Black and minority ethnic groups were hospitalised for unipolar depression, whereas this diagnosis was common in the White European group (41%). Another factor is country of birth. The group who were classified as Black British were no more likely to be categorised as lacking capacity than the White European group, suggesting that some of the effect of ethnicity may be due to different cultural understandings, such as differences in the use of language.
Predictors of capacity
A strong association was seen between lower insight scores and mental
incapacity. Although the relationship between use of the Mental Health Act
1983 and insight is predictable (McEvoy
et al, 1989; David
et al, 1992), the relationship between mental capacity
and insight has received little attention. Insight has at least three
overlapping dimensions: awareness of illness, the ability to relabel unusual
mental experiences as pathological, and treatment adherence
(David, 1990). We suggest that
there is conceptual overlap between insight and mental capacity and the
respective components of each. For example, impairments in understanding,
appreciation, reasoning or ability to express a choice would be reflected in
one or more of the dimensions of insight. It also seems probable that the
associations seen between mental incapacity and a diagnosis of psychosis or
mania and with the experience of delusional beliefs are mediated through the
effect of poor insight. Sanz et al
(1998) have previously shown
that measures of insight relate strongly to the presence of delusions,
grandiosity (inversely) and depression (positively).
Cognitive impairment has been shown to be an independent predictor of incapacity in general hospital in-patients (Raymont et al, 2004). The results from the present study show an association between lower MMSE scores and mental incapacity that borders on statistical significance. The difference between these findings may be explained by the younger mean age of patients in this study (37.2 years) compared with a mean age of 64.2 years in the study looking at capacity in general hospital patients (Raymont et al, 2004). Furthermore, the distribution of scores suggested a ceiling effect and hence insensitivity to potential differences. In a study of middle-aged and older out-patients with schizophrenia (mean age 50.2 years), the patients level of capacity (using MacCATT sub-scale scores) was strongly associated with cognitive test performance but not with severity of psychopathology (Palmer et al, 2004). The authors suggest that their findings, although unexpected, are partly explained by the out-patient status (and therefore relative stability) of the participants and are consistent with the overall findings in functional outcome studies of schizophrenia that neuropsychological test performance tends to be a better predictor of everyday functioning than the severity of psychopathology alone (Green, 1996; Green et al, 2000; Evans et al, 2003). Severity of psychopathology, as measured by BPRS scores, was not closely associated with incapacity in this study although there was an association with the presence of delusions. A limitation of this study arises from using the MMSE as the sole measure of cognitive impairment: it is possible that as a result the potential association between this and incapacity may have been inadequately assessed.
Implications
We believe this study to be important because it is the first to use the
MacCATT and a clinical interview to reach an overall judgement of
capacity and describe the prevalence of mental incapacity in a consecutive
sample of psychiatric patients. The consecutive sample design ensured that
both voluntarily and involuntarily admitted patients with a range of
psychiatric diagnoses were included. The sample was therefore reasonably
representative of the heterogeneous mix of patients who require admission to a
psychiatric in-patient unit. We are aware of one other study
(Bellhouse et al,
2003) that was concerned with global capacity judgements in
admissions to psychiatric or learning disability services but the numbers
recruited for our study were larger (n=112 compared with
n=41), conferring additional statistical power to our findings.
Coercion in psychiatry can be defined as any attempt to impose treatment against a patients wishes (Bindman, 2004). Individuals lacking capacity were significantly more likely to be detained under the Mental Health Act 1983 and to have higher scores of perceived coercion than patients who had capacity to make treatment decisions. When the group of patients who lacked capacity was considered separately, the detained patients still experienced higher levels of coercion than voluntary patients who lacked capacity. The same pattern was seen in the group of patients with capacity (see Table 4). Unsurprisingly, involuntary admission to hospital is more closely associated with perceived coercion than the presence or absence of capacity.
Six participants with treatment-related decisional capacity had been detained under the Mental Health Act 1983. Proponents of capacity-based mental health legislation feel that the current Mental Health Act (1983) discriminates against these individuals by not respecting their wishes to refuse treatment in the way that legislation for physical illnesses allows. This group constituted 12.2% of those with treatment-related capacity and 5.4% of our sample as a whole. None was in their first admission and levels of psychopathology were not high. Further in-depth analysis of these patients journeys would be of value. Perhaps the Mental Health Act 1983 was used because of anticipated risks based on previous knowledge of the patients rather than their manifest levels of psychopathology.
The other notable group were the 19 voluntary patients who lacked capacity but were assenting (or non-objecting) to treatment and therefore fell into the Bournewood gap, so called because of the lack of legal safeguards in place for them (R v. Bournewood Community and Mental Health NHS Trust, 1999). The Expert Committees recommendation that capacity-based mental health legislation be introduced was not accepted by the government and is not reflected in the current Draft Mental Health Bill (Expert Committee, 1999). However, the Mental Capacity Act 2005, recently passed by parliament, provides a legal framework for the provision of treatment in the case of patients who lack capacity, and its implementation will make the assessment of mental capacity increasingly important in clinical practice. The degree of patient insight has a close relationship to capacity and the need for involuntary treatment. It remains possible that this construct, although no less complex than capacity, is more intuitive to mental health professionals and may provide a more reliable basis for coercive-treatment decisions.
Insight, ethnicity and capacity
This cross-sectional study has provided a snapshot of
incapacity among psychiatric in-patients. Our results suggest that insight has
an important effect on capacity and this will be explored in more depth in
future. The possible effect of ethnicity on capacity is also an important
finding. Ethnicity is the most widely studied and important demographic
variable in relation to the use of the Mental Health Act 1983, with higher
proportions of Black than White patients being admitted to hospital on an
involuntary basis (Wall et al,
1999). Decisional capacity is a complex construct that is
determined by the interaction of patient characteristics with contextual and
environmental factors (Palmer et
al, 2004) and it is important that we try to improve our
understanding of any potential ethnic biases that occur when it is assessed.
Fluctuations and improvements in capacity should be studied and may lead to
interventions to enhance decisional capacity.
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Received for publication January 24, 2005. Revision received April 11, 2005. Accepted for publication May 3, 2005.
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