Skip to main content
×
Home
    • Aa
    • Aa

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

  • G. S. Owen (a1), A. S. David (a1), G. Richardson (a2), G. Szmukler (a3), P. Hayward (a4) and M. Hotopf (a1)...
Abstract
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.

Copyright
Corresponding author
*Address for correspondence: Dr G. S. Owen, Institute of Psychiatry, Weston Education Centre, Cutcombe Rd, London SE5 9RJ, UK. (Email: g.owen@iop.kcl.ac.uk)
References
Hide All
Amador X (2004). Insight and psychosis. In Insight and Psychosis, 2nd edn (ed. Amador X. and David A.), pp. 331. Oxford University Press: Oxford.
APA (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edn, text revision. American Psychiatric Association: Washington, DC.
Applebaum PS (2007). Assessment of patient's competence to consent to treatment. New England Journal of Medicine 357, 18341840.
Beck-Sandler A (1998). Is insight meaningful? Journal of Mental Health 7, 2534.
Bellhouse J, Holland AJ, Clare ICH, Gunn M, Watson P (2003 a). Capacity-based mental health legislation and its impact on clinical practice: (1) admission to hospital. Journal of Mental Health Law (July), 923.
Bellhouse J, Holland AJ, Clare ICH, Gunn M, Watson P (2003 b). Capacity-based mental health legislation and its impact on clinical practice: (2) treatment in hospital. Journal of Mental Health Law (July), 2436.
Cairns R, Maddock C, David AS, Hayward P, Richardson G, Szmukler G, Hotopf M (2005). Prevalence and predictors of mental incapacity in psychiatric in-patients. British Journal of Psychiatry 187, 379385.
Carpenter WT Jr., Gold JM, Lahti AC, Queern CA, Conley RR, Bartko JJ, Kovnick J, Appelbaum PS (2000). Decisional capacity for informed consent in schizophrenia research. Archives of General Psychiatry 57, 533538.
David A (1990). Insight and psychosis. British Journal of Psychiatry 161, 599602.
David AS (1998). Commentary on: ‘Is insight into psychosis meaningful?’. Journal of Mental Health 7, 579583.
Dawson J, Szmukler G (2006). Fusion of mental health and incapacity legislation. British Journal of Psychiatry 188, 504509.
Department of Health (2008). Code of Practice: Mental Health Act 1983. The Stationery Office: London.
Diesfeld K (2003). Insight on ‘insight’: the impact of extra-legislative factors on decisions to discharge detained patients. In Involuntary Detention and Therapeutic Jurisprudence (ed. Diesfeld K. and Freckelton I.), pp. 359382. Ashgate: Aldershot.
Etchells E, Katz MR, Shuchman M, Wong G, Workman S, Choudhry NK, Craven J, Singer PA (1997). Accuracy of clinical impressions and Mini-Mental State Exam scores for assessing capacity to consent to major medical treatment: comparison with criterion-standard psychiatric assessments. Psychosomatics: Journal of Consultation and Liaison Psychiatry 38, 239245.
Fulford KWM (2004). Insight and delusion: from Jaspers to Kraeplin and back again via Austin. In Insight and Psychosis, 2nd edn (ed. Amador X. and David A.), pp. 5178. Oxford University Press: Oxford.
Grisso T, Appelbaum PS, Hill-Fotouhi C (1997). The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions. Psychiatric Services 48, 14151419.
Kress K (2004). Why lack of insight should have a central place in mental health law. In Insight and Psychosis, 2nd edn (ed. Amador X. and David A.), pp. 257279. Oxford University Press: Oxford.
Law Commission (1995). Mental Incapacity. The Stationery Office: London.
McEvoy JP, Appelbaum PS, Apperson LJ, Geller JL, Freter S (1989). Why must some schizophrenic patients be involuntarily committed? The role of insight. Comprehensive Psychiatry 30, 1317.
Okai D, Owen G, McGuire H, Singh S, Churchill R, Hotopf M (2007). Mental capacity in psychiatric patients: systematic review. British Journal of Psychiatry 191, 291297.
Owen GS, Richardson G, David AS, Szmukler G, Hayward P, Hotopf M (2008). Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: a cross sectional study. British Medical Journal 337, 448.
Palmer BW, Dunn LB, Appelbaum PS, Jeste DV (2004). Correlates of treatment-related decision-making capacity among middle-aged and older patients with schizophrenia. Archives of General Psychiatry 61, 230236.
Palmer BW, Dunn LB, Appelbaum PS, Mudaliar S, Thal L, Henry R, Golshan S, Jeste DV (2005). Assessment of capacity to consent to research among older persons with schizophrenia, Alzheimer disease, or diabetes mellitus: comparison of a 3-item questionnaire with a comprehensive standardized capacity instrument. Archives of General Psychiatry 62, 726733.
Palmer BW, Jeste DV (2006). Relationship of individual cognitive abilities to specific components of decisional capacity among middle-aged and older patients with schizophrenia. Schizophrenia Bulletin 32, 98106.
PsychCorp (1999). Wechsler Abbreviated Scale of Intelligence – Manual. PsychCorp: San Antonio, TX.
Raymont V, Bingley W, Buchanan A, David AS, Hayward P, Wessely S, Hotopf M (2004). Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study. Lancet 364, 14211427.
Sanz M, Constable G, Lopez-Ibor I, Kemp R, David AS (1998). A comparative study of insight scales and their relationship to psychopathological and clinical variables. Psychological Medicine 28, 437446.
Singh SP, Greenwood N, White S, Churchill R (2007). Ethnicity and the Mental Health Act 1983. British Journal of Psychiatry 191, 99105.
Stromberg CD, Stone AA (1983). A model state law on civil commitment of the mentally ill. Harvard Journal on Legislation 20, 275396.
Ventura J, Green MF, Shaner A, Liberman RP (1993). Training and quality assurance with the Brief Psychiatric Rating Scale: ‘The drift buster’. International Journal of Methods in Psychiatric Research 3, 221244.
WHO (1992). The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization: Geneva.
Wong JG, Cheung EP, Chen EY (2005). Decision-making capacity of inpatients with schizophrenia in Hong Kong. Journal of Nervous and Mental Disease 193, 316322.
Wuensch K (2007). Construct Confidence Interval for Cohen's d (http://core.ecu.edu/psyc/wuenschk/SPSS/SPSS-Programs.htm).
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Keywords:

Metrics

Full text views

Total number of HTML views: 4
Total number of PDF views: 97 *
Loading metrics...

Abstract views

Total abstract views: 405 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 23rd October 2017. This data will be updated every 24 hours.