Background Mental capacity is central to legal and ethical debates on the use of compulsion in psychiatry.

Aims To describe the clinical epidemiology of mental incapacity in patients with psychiatric disorders, including interrater reliability of assessments, frequency in the psychiatric population and associations of mental incapacity.

Method Cross-sectional studies of capacity to consent to treatment for psychiatric patients were systematically reviewed from Medline, EMBASE and PsycInfo databases. Information on the reliability of assessments, frequency and associations of mental incapacity was extracted.

Results Out of 37 papers reviewed, 29 different capacity assessment tools were identified. Studies were highly heterogeneous in their measurement and definitions of capacity. Interrater reliabilities between tools were high. Studies indicate incapacity is common (median 29%) but the majority of psychiatric in-patients are capable of making treatment decisions. Psychosis, severity of symptoms, involuntary admission and treatment refusal were the strongest risk factors for incapacity.

Conclusions Mental capacity can be reliably assessed. The majority of psychiatric in-patients have capacity, and socio-demographic variables do not have a major impact but clinical ones do.

/pdf/mental-capacity-in-psychiatric-patients-systematic-review-2g2jvi83oc.pdf

Mental capacity in psychiatric patients: Systematic review.

Ruissen AM, Widdershoven GAM, Meynen G, Abma TA, van Balkom AJLM. A systematic review of the literature about competence and poor insight.



Objective:  Formally, incompetence implies that a patient cannot meet the legal requirements for informed consent. Our aim was to review the scientific literature on the relationship between competence and insight in patients with psychiatric disorders, how competence and insight are connected in these patients and whether there are differences in competence and insight among patients with different disorders.



Method:  A search in PubMed/Medline was performed. Articles were assessed on relevance criteria by two independent reviewers. Study design, population, variables, and outcomes were extracted.



Results:  Seven articles were included on studies of psychiatric inpatients and outpatients and of psychotic and non-psychotic patients. All studies used the MacArthur Competence Assessment Tool (MacCAT). All studies but one found a strong correlation between poor insight and incompetence. Psychotic patients with poor insight are very likely to be incompetent, and psychotic patients with adequate insight are generally competent. One well-executed study showed that in non-psychotic disorders, however, another relationship emerges; competence and insight do not completely overlap in these patients.



Conclusion:  Most incompetent psychotic patients have poor insight, but non-psychotic patients with adequate insight were incompetent in a substantial number of cases. In sum: non-psychotic patients with adequate insight can be incompetent.

A systematic review of the literature about competence and poor insight

Many of the world’s mental health acts, including all Australian legislation, allow for the coercive detention and treatment of people with mental illnesses if they are deemed likely to harm themselves or others. Numerous authors have argued that legislated powers to impose coercive treatment in psychiatric illness should pivot on the presence or absence of capacity not likely harm, but no Australian act uses this criterion. In this paper, I add a novel element to these arguments by comparing the use of the harm to others justification for coercive treatment in mental illness with its use in illness due to infectious disease, and suggest a double standard applies. People with mental illness are subjected to coercive treatments at levels of risk to others far, far lower than would precipitate coercive treatment in people with influenza. In effect, this element of mental health legislation represents an example of sanism—state-sanctioned discrimination against people with mental illnesses.

https://link.springer.com/content/pdf/10.1007%2Fs11673-010-9270-2.pdf

One Flu Over The Cuckoo’s Nest: Comparing Legislated Coercive Treatment for Mental Illness with that for Other Illness

Categorical mental capacity for treatment decisions among psychiatry inpatients in Ireland

The appointment of a guardian is an important complex process that significantly infringes upon the individuals liberty and autonomy; however it is a necessary paternalistic intervention when called for. The law does not provide precise criteria for the appointment of a guardian, though physicians have tried to determine criteria for the initiation of the process. The authors present a review of the various aspects of the assessment of the need for guardianship and the appointment process for guardians for adults in Israel. The medical document that will ultimately determine the need for the appointment of a guardian for an elderly person should be the product of a comprehensive medical, psychiatric and cognitive evaluation and an accurate evaluation of competence.

Guardianship appointment: current status in Israel.

Informed consent and insight are among the most important issues in medical treatment, especially for psychiatric patients. In this study, we examined the competence to consent to psychiatric hospitalization of 113 psychiatric patients who were voluntarily admitted to a mental hospital in various psychotic states and compared it with their insight. We found a significant correlation between the patients' competence and insight into their illnesses. There is a discussion of the problematic issues of informed consent, competence and psychosis and the importance of insight in the context of mental illness.

Insight and competence to consent to psychiatric hospitalization.

[Guardianship nomination: rethinking the decision making process].

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Insight and competence to consent to psychiatric hospitalization.

[Guardianship nomination: rethinking the decision making process].