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Prevalence and predictors of mental incapacity in psychiatric in-patients

  • Ruth Cairns (a1), Clementine Maddock (a1), Alec Buchanan (a2), Anthony S. David (a1), Peter Hayward (a3), Genevra Richardson (a4), George Szmukler (a5) and Matthew Hotopf (a5)...
Abstract
Background

Little is known about the proportion of psychiatric in-patients who lack capacity to make treatment decisions, or the associations of lack of capacity.

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 lack of mental capacity.

Method

Patients (n=112) were interviewed soon after admission to hospital and a binary judgement 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 mental incapacity. 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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Copyright
Corresponding author
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@iop.kcl.ac.uk
Footnotes
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See pp. 372–378, this issue.

Declaration of interest

None. The study was funded by the Wellcome Trust.

Footnotes
References
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Prevalence and predictors of mental incapacity in psychiatric in-patients

  • Ruth Cairns (a1), Clementine Maddock (a1), Alec Buchanan (a2), Anthony S. David (a1), Peter Hayward (a3), Genevra Richardson (a4), George Szmukler (a5) and Matthew Hotopf (a5)...
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eLetters

MENTAL RETARDATION - YET ANOTHER ISSUE IN MENTAL CAPACITY TO CONSENT

Yatan PS Balhara, resident, department of psychiatry
18 November 2005

Mental retardation/ sub normal intelligence is another important factor that poses the clinicians with the clinical dilemma to assess theircapacity to consent. This becomes even more dicey when the reason to give the consent is not directly related to the patient's beneficience, although it has got a strong impact on his/ her future. The current authorwith two other authors (case report published elsewhere)have repored one such dialemma faced in case of a lady with sub normal intelligence, whose husband was in need of a renal transplantation because of an end stage renal disease . We were put in a great clinical turmoil because of the lack of the well defined laws on the issue and the specific problem because of the husband being the only care provider to the patient. We hadto decide whether the act of donation of the kidney would be of benificienc to the patient and whether it wouldn't violate the principle of "first do no harm" in light of the lack of the psychosocial support to the patient and her daughter in case the husband is denied the transplant and the likely poor prognosis. First of all we had to decide if she was competent enough to understand the complexities of the issue and its possible implications? Does her subnormal intelligence (mild mental retardation) leave her with a capacity to comprehend the issues concerned?In order to assess her competence in this regard what all criteria need tobe looked upon?

The basic tenets of informed consent are based on the elements of information, decisional capacity and voluntarism. An individual’s decisionto give or withhold consent cannot be considered valid unless he or she has the capacity to make that decision. Nevertheless, this presumption maybe called into question, particularly if he or she has a “mental disability”. Any decision on the part of the clinician should be ethically sound. The clinician has to be sure that he has done justice to the subject and importantly has not gone beyond the law while making any decision.

According to a recent Consensus Statement on Live Organ Donors “the person who gives consent for a live organ transplant should be competent, willing to donate, free from coercion, medically and psychosocially suitable and fully informed of the risks, benefits and alternative treatment available to the recipient” (2)

In India, neither the Organ Transplant Act, 1994 (3) nor the Mental Health Act, 1987 (4) provide any light into this matter, both of which aresilent regarding the capabilities of the mentally challenged to take such decisions. According to court rulings in U.K”an operation can be performedon a mentally retarded adult without his consent only if the weight of professional opinion is that the procedure is in the individuals’ interest” (5).

referencs-

1. Malhotra S, Balhara Y PS, Varghese ST. Organ donation in mental retardation: A clinical dilemma.Indian Journal of Medical Sciences.2004, 58(10);444.2. WORLD HEALTH ORGANIZATION. Guiding principles on human organ transplantation. Lancet 1991;337:14703. THE TRANSPLANTATION OF HUMAN ORGANS ACT (INDIA), 19944. THE MENTAL HEALTH ACT OF INDIA (INDIA), 19875. LUTTRELL S. Making decisions about medical treatment for mentally incapable adults in U.K . Lancet 1997; 350:950-953.
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