Skip to main content

Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis

  • Amanda Larkin (a1) and Paul Hutton (a2)

The evidence on factors that may influence treatment decisional capacity (‘capacity’) in psychosis has yet to be comprehensively synthesised, which limits the development of effective strategies to improve or support it.


To determine the direction, magnitude and reliability of the relationship between capacity in psychosis and a range of clinical, demographic and treatment-related factors, thus providing a thorough synthesis of current knowledge.


We conducted a systematic review, meta-analytical and narrative synthesis of factors that help or hinder treatment decision-making capacity in psychosis, assessing the direction, magnitude, significance and reliability of reported associations.


We identified 23 relevant studies (n = 1823). Psychotic symptoms had small, moderate and strong associations with appreciation, understanding and reasoning respectively. Both verbal cognitive functioning and duration of education had small to moderate correlations with understanding and reasoning. Better capacity was also associated with better insight, better metacognitive ability, higher anxiety and lower perceived coercion. No linear relationship with depression was observed. Interventions linked to improved capacity over time were in-patient care, information simplification, shared decision-making and metacognitive training.


Although much is known about the role of symptoms and other clinical variables, effective and acceptable psychological interventions to support capacity in this group are lacking.

    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis
      Available formats
Corresponding author
Amanda Larkin, Psychosis Research Unit, Rico House, Prestwich M25 3BL, UK. Email:
Hide All

Declaration of interest


Hide All
1 Appelbaum, PS, Grisso, T. The MacArthur Treatment Competence Study. I: Mental illness and competence to consent to treatment. Law Hum Behav 1995; 19: 105–26.
2 Owen, GS, Freyenhagen, F, Richardson, G, Hotopf, M. Mental capacity and decisional autonomy: an interdisciplinary challenge. Inquiry 2009; 51: 79107.
3 Pitt, L, Kilbride, M, Nothard, S, Welford, M, Morrison, A. Researching recovery from psychosis: a user-led project. Psychiatr Bull 2007; 31: 5560.
4 Law, H, Morrison, AP. Recovery in psychosis: a Delphi study with experts by experience. Schizophr Bull 2014; 40: 1347–55.
5 Lepping, P, Raveesh, BN. Overvaluing autonomous decision-making. Br J Psychiatry 2014; 204: 12.
6 Donnelly, MMA. Healthcare Decision-Making and The Law: Autonomy, Capacity and the Limits of Liberalism. Cambridge University Press, 2010.
7 Lepping, P, Stanly, T, Turner, J. Systematic review on the prevalence of lack of capacity in medical and psychiatric settings. Clin Med (Lond) 2015; 15: 337–43.
8 Seyfried, L, Ryan, KA, Kim, SY. Assessment of decision-making capacity: views and experiences of consultation psychiatrists. Psychosomatics 2013; 54: 115–23.
9 Hamann, J, Cohen, R, Leucht, S, Busch, R, Kissling, W. Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatry 2005; 162: 2382–4.
10 National Collaborating Centre for Mental Health. Psychosis and Schizophrenia in Adults: Prevention and Management (Clinical Guideline CG178). NICE, 2014.
11 Royal College of Psychiatrists. Report of the Second Round of the National Audit of Schizophrenia (NAS) 2014. Healthcare Quality Improvement Partnership, 2014.
12 Hamann, J, Mendel, R, Cohen, R, Heres, S, Ziegler, M, Buhner, M, et al. Psychiatrists' use of shared decision making in the treatment of schizophrenia: patient characteristics and decision topics. Psychiatr Serv 2009; 60: 1107–12.
13 British Medical Association, Law Society. Assessment of Mental Capacity: A Practical Guide for Doctors and Lawyers (4th edn). Law Society Publishing, 2015.
14 Carpenter, WT, Gold, JM, Lahti, AC, Queern, CA, Conley, RR, Bartko, JJ, et al. Decisional capacity for informed consent in schizophrenia research. Arch Gen Psychiatry 2000; 57: 533–8.
15 Naughton, M, Nulty, A, Abidin, Z, Davoren, M, O'Dwyer, S, Kennedy, HG. Effects of group metacognitive training (MCT) on mental capacity and functioning in patients with psychosis in a secure forensic psychiatric hospital: a prospective-cohort waiting list controlled study. BMC Res Notes 2012; 5: 302.
16 Okai, D, Owen, G, McGuire, H, Singh, S, Churchill, R, Hotopf, M. Mental capacity in psychiatric patients: systematic review. Br J Psychiatry 2007; 191: 291–7.
17 Dunn, LB. Capacity to consent to research in schizophrenia: the expanding evidence base. Behav Sci Law 2006; 24: 431–45.
18 Sturman, ED. The capacity to consent to treatment and research: a review of standardized assessment tools. Clin Psychol Rev 2005; 25: 954–74.
19 Jeste, DV, Depp, CA, Palmer, BW. Magnitude of impairment in decisional capacity in people with schizophrenia compared to normal subjects: an overview. Schizophr Bull 2006; 32: 121–8.
20 Ruissen, AM, Widdershoven, GA, Meynen, G, Abma, TA, van Balkom, AJ. A systematic review of the literature about competence and poor insight. Acta Psychiatr Scand 2012; 125: 103–13.
21 Palmer, BW, Savla, GN. The association of specific neuropsychological deficits with capacity to consent to research or treatment. J Int Neuropsychol Soc 2007; 13: 1047–59.
22 Guyatt, GH, Oxman, AD, Vist, GE, Kunz, R, Falck-Ytter, Y, Alonso-Coello, P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924–6.
23 Taylor, PJ, Hutton, P, Wood, L. Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis. Psychol Med 2015; 45: 911–26.
24 Dudley, R, Taylor, P, Wickham, S, Hutton, P. Psychosis, delusions and the ‘jumping to conclusions’ reasoning bias: a systematic review and meta-analysis. Schizophr Bull 2016; 42: 652–65.
25 Williams, JW, Plassman, BL, Burke, J, Holsinger, T, Benjamin, S. Preventing Alzheimer's Disease and Cognitive Decline. Evidence Report/Technology Assessment 193. US Agency for Healthcare Research and Quality, 2010.
26 Higgins, JP, Altman, DG, Gotzsche, PC, Juni, P, Moher, D, Oxman, AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928.
27 DerSimonian, R, Laird, N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177–88.
28 Borenstein, M. Introduction to Meta-Analysis. Wiley, 2009.
29 Cohen, J. Statistical Power Analysis For The Behavioral Sciences (2nd edn). Erlbaum, 1988.
30 Ioannidis, JP, Trikalinos, TA. The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey. CMAJ 2007; 176: 1091–6.
31 Grisso, T, Appelbaum, PS, Hill-Fotouhi, C. The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions. Psychiatr Serv 1997; 48: 1415–9.
32 Rutledge, E, Kennedy, M, O'Neill, H, Kennedy, HG. Functional mental capacity is not independent of the severity of psychosis. Int J Law Psychiatry 2008; 31: 918.
33 Koren, D, Poyurovsky, M, Seidman, U, Goldsmith, M, Wenger, S, Klein, EM. The neuropsychological basis of competence to consent in first-episode schizophrenia: a pilot metacognitive study. Biol Psychiatry 2005; 57: 609–16.
34 Mandarelli, G, Parmigiani, G, Tarsitani, L, Frati, P, Biondi, M, Ferracuti, S. The relationship between executive functions and capacity to consent to treatment in acute psychiatric hospitalization. J Empir Res Hum Res Ethics 2012; 7: 6370.
35 Cairns, R, Maddock, C, Buchanan, A, David, AS, Hayward, P, Richardson, G, et al. Reliability of mental capacity assessments in psychiatric in-patients. Br J Psychiatry 2005; 187: 372–8.
36 Capdevielle, D, Raffard, S, Bayard, S, Garcia, F, Baciu, O, Bouzigues, I, et al. Competence to consent and insight in schizophrenia: is there an association? A pilot study. Schizophr Res 2009; 108: 272–9.
37 Owen, GS, David, AS, Richardson, G, Szmukler, G, Hayward, P, Hotopf, M. Mental capacity, diagnosis and insight in psychiatric in-patients: a cross-sectional study. Psychol Med 2009; 39: 1389–98.
38 Elbogen, EB, Swanson, JW, Appelbaum, PS, Swartz, MS, Ferron, J, Van Dorn, RA, et al. Competence to complete psychiatric advance directives: effects of facilitated decision making. Law Hum Behav 2007; 31: 275–89.
39 Raffard, S, Fond, G, Brittner, M, Bortolon, C, Macgregor, A, Boulenger, JP, et al. Cognitive insight as an indicator of competence to consent to treatment in schizophrenia. Schizophr Res 2013; 144: 118–21.
40 Wong, JG, Cheung, EP, Chen, EY. Decision-making capacity of inpatients with schizophrenia in Hong Kong. J Nerv Ment Dis 2005; 193: 316–22.
41 Moritz, S, Woodward, TS, Balzan, R. Is metacognitive training for psychosis effective? Expert Rev Neurother 2016; 16: 105–7.
42 Munetz, MR, Roth, LH. Informing patients about tardive dyskinesia. Arch Gen Psychiatry 1985; 42: 866–71.
43 Palmer, BW, Nayak, GV, Dunn, LB, Appelbaum, PS, Jeste, DV. Treatment-related decision-making capacity in middle-aged and older patients with psychosis: a preliminary study using the MacCAT-T and HCAT. Am J Geriatr Psychiatry 2002; 10: 207–11.
44 Kleinman, I, Schachter, D, Jeffries, J, Goldhamer, P. Informed consent and tardive dyskinesia. Long-term follow-up. J Nerv Ment Dis 1996; 184: 517–22.
45 Kennedy, M, Dornan, J, Rutledge, E, O'Neill, H, Kennedy, HG. Extra information about treatment is too much for the patient with psychosis. Int J Law Psychiatry 2009; 32: 369–76.
46 Wong, JG, Clare, CH, Holland, AJ, Watson, PC, Gunn, M. The capacity of people with a ‘mental disability’ to make a health care decision. Psychol Med 2000; 30: 295306.
47 Owen, GS, Ster, IC, David, AS, Szmukler, G, Hayward, P, Richardson, G, et al. Regaining mental capacity for treatment decisions following psychiatric admission: a clinico-ethical study. Psychol Med 2011; 41: 119–28.
48 Dornan, J, Kennedy, M, Garland, J, Rutledge, E, Kennedy, HG. Functional mental capacity, treatment as usual and time: magnitude of change in secure hospital patients with major mental illness. BMC Res Notes 2015; 8: 566.
49 Hamann, J, Mendel, R, Meier, A, Asani, F, Pausch, E, Leucht, S, et al. ‘How to speak to your psychiatrist’: shared decision-making training for inpatients with schizophrenia. Psychiatr Serv 2011; 62: 1218–21.
50 Turner, DT, van der Gaag, M, Karyotaki, E, Cuijpers, P. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. Am J Psychiatry 2014; 171: 523–38.
51 Eichner, C, Berna, F. Acceptance and efficacy of metacognitive training (MCT) on positive symptoms and delusions in patients with schizophrenia: a meta-analysis taking into account important moderators. Schizophr Bull 2016; 42: 952–62.
52 Cella, M, Preti, A, Edwards, C, Dow, T, Wykes, T. Cognitive remediation for negative symptoms of schizophrenia: a network meta-analysis. Clin Psychol Rev 2016; 52: 4351.
53 Cella, M, Reeder, C, Wykes, T. Lessons learnt? The importance of metacognition and its implications for cognitive remediation in schizophrenia. Front Psychol 2015; 6: 1259.
54 Wykes, T, Huddy, V, Cellard, C, McGurk, SR, Czobor, P. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry 2011; 168: 472–85.
55 Belvederi Murri, M, Respino, M, Innamorati, M, Cervetti, A, Calcagno, P, Pompili, M, et al. Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis. Schizophr Res 2015; 162: 234–47.
56 Belvederi Murri, M, Amore, M, Calcagno, P, Respino, M, Marozzi, V, Masotti, M, et al. The ‘insight paradox’ in schizophrenia: magnitude, moderators and mediators of the association between insight and depression. schizophr Bull 2016; 42: 1225–33.
57 Altman, DG, Royston, P. The cost of dichotomising continuous variables. BMJ 2006; 332: 1080.
58 Shek, E, Lyons, D, Taylor, M. Understanding ‘significant impaired decision-making ability’ with regard to treatment for mental disorder: an empirical analysis. The Psychiatrist 2010; 34: 239–42.
59 Allen, N. Is capacity “in sight”? J Ment Health Law 2009; Winter: 165–70.
60 Cooke, A (ed). Understanding Psychosis and Schizophrenia: Why People Sometimes Hear Voices, Believe Things that Others Find Strange, or Appear Out of Touch with Reality and what Can Help. British Psychological Society, 2014.
61 Kendler, KS, Campbell, J. Interventionist causal models in psychiatry: repositioning the mind-body problem. Psychol Med 2009; 39: 881–7.
62 Garety, PA, Kuipers, E, Fowler, D, Freeman, D, Bebbington, PE. A cognitive model of the positive symptoms of psychosis. Psychol Med 2001; 31: 189–95.
63 Kahneman, D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol 2003; 58: 697720.
64 Armitage, CJ, Conner, M. Efficacy of the theory of planned behaviour: a meta-analytic review. Br J Soc Psychol 2001; 40(Pt 4): 471–99.
65 Hartley, CA, Phelps, EA. Anxiety and decision-making. Biol Psychiatry 2012; 72: 113–8.
66 Mukherjee, D, Kable, JW. Value-based decision-making in mental illness: a meta-analysis. Clin Psychol Sci 2014; 2: 767–82.
67 Selten, JP, van der Ven, E, Rutten, BP, Cantor-Graae, E. The social defeat hypothesis of schizophrenia: an update. Schizophr Bull 2013; 39: 1180–6.
68 Morrison, AP. The interpretation of intrusions in psychosis: an integrative cognitive approach to hallucinations and delusions. Behav Cogn Psychother 2001; 29: 257–76.
69 Howes, OD, Murray, RM. Schizophrenia: an integrated sociodevelopmentalcognitive model. Lancet 2014; 383: 1677–87.
70 Di, X, Cheng, H. Competence of consent and associated factors among inpatients of schizophrenia in Changsa, China. J Schizophr Res 2013; 150: 325–6.
71 Grisso, T, Appelbaum, PS. Mentally ill and non-mentally-ill patients' abilities to understand informed consent disclosures for medication: preliminary data. Law Hum Behav 1991; 15: 377.
72 Grisso, T, Appelbaum, PS. The MacArthur Treatment Competence Study. Ill: Abilities of patients to consent to psychiatric and medical treatments. Law Hum Behav 1995; 19: 149.
73 Howe, V, Foister, K, Jenkins, K, Stene, L, Copolov, D, Neks, N. Competence to give informed consent in acute psychosis is associated with symptoms rather than diagnosis. Schizophr Res 2005; 77: 211–4.
74 Owen, GS, Richardson, G, David, AS, Szmukler, G, Hayward, P, Hotopf, M. Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study. BMJ 2008; 337: a448.
75 Schacter, D, Kleinman, I, Prendergast, P, Remington, G, Schertzer, S. The effect of psychopathology on the ability of schizophrenic patients to give informed consent. J Nerv Ment Dis 1994; 182: 360–2.
Recommend this journal

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

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 69 *
Loading metrics...

Abstract views

Total abstract views: 154 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 22nd April 2018. This data will be updated every 24 hours.

Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis

  • Amanda Larkin (a1) and Paul Hutton (a2)
Submit a response


No eLetters have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *