© 2005 The Royal College of Psychiatrists
Prevalence and predictors of mental incapacity in psychiatric in-patients
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.
372–378, this issue. 
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Background Little is known about the proportion of psychiatric in-patients who lackcapacity to make treatment decisions, or the associations of lackof 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 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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In contrast to the legal position in relation to the provision of treatment for a physical disorder, the Mental Health Act 1983 in England and Wales attributes little significance to the patient’s capacity to consent. It provides a legal framework for the detention in hospital of individuals with a mental disorder and for their treatment for that disorder, irrespective of their capacity to withhold consent. In only a few specific situations is the assessment of capacity required: continuation of treatment beyond 3 months in detained patients, electroconvulsive therapy, psychosurgery and implantation of sex hormones. Only in the last two situations is the absence of capacity or the absence of consent prohibitive of the provision of treatment (Bartlett & Sandland, 2003). Despite current debate about the place of mental capacity in mental health legislation, there is surprisingly little systematic research of the prevalence of capacity in clinical populations (Szmukler & Holloway, 1998; Expert Committee, 1999; Zigmond & Holland, 2000). One previous study described the proportion of patients lacking capacity (20%) in a sample of patients admitted for treatment to psychiatric or learning disability services, but this was limited by its small sample size (n=41) (Bellhouse et al, 2003). Other studies have compared the numbers of impaired patients in different diagnostic groups with each other and with normal controls for the components of treatment-related decisional capacity, but have not investigated global capacity judgements (Grisso & Appelbaum, 1995a,b; Grisso et al, 1997; Vollmann et al, 2003; Palmer et al, 2004). The objectives of the current study were to determine the prevalence of psychiatric in-patients who lack capacity to make key decisions about their treatment and to establish whether mental incapacity is associated with specific demographic or clinical factors, in particular use of the Mental Health Act 1983, insight, perceived coercion, cognitive impairment and psychopathology.
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Participants
Consecutively admitted patients to three general adult psychiatric wards at the Maudsley Hospital, London, were approached for inclusion in this study over a 9-month period. These wards cover the catchment area of South Southwark, an inner-city deprived area, with an ethnically diverse population. The local research ethics committee approved the study and after complete description of the study to the participants, written informed consent was obtained. A total of 112 patients agreed to participate and all were interviewed within 9 days of admission (111 within 7 days of admission). Exclusion criteria included being unable to consent to taking part in research, being on no regular prescribed psychotropic medication or receiving medication for the sole purpose purpose of a medically assisted alcohol detoxification, and speaking no English.
Measurement of capacity
The MacArthur Competence Assessment Tool for Treatment (MacCAT–T) 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 patient’s 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
patient’s 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 patient’s 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 patient’s main treatment. This information was disclosed to the patient during the MacCAT–T 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 MacCAT–T criteria and made a global judgement about the patient’s capacity to make a treatment decision, based on information from both the MacCAT–T 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 MacCAT–T, the Brief Psychiatric
Rating Scale (BPRS) (Ventura et
al, 1993), the Expanded Schedule for Assessment of Insight
(SAI–E) (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 SAI–E 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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Participant characteristics
Out of 235 newly admitted patients, 189 were eligible for inclusion in the study and 112 (59.3%) agreed to take part. Out of the remaining 77, 64 (33.9%) refused to take part and 13 (6.9%) were eligible but not included because there was a high perceived risk of violence to the interviewer (9), the patient was discharged before being invited to participate (3), or the patient had absconded from the ward (1). Of the patients who were excluded, 17 were considered by medical or senior nursing staff to be too unwell to assent to taking part in research. Of these, 8 were mute and 9 had severe thought disorder or paranoid delusions. A further 24 excluded patients were on no regular prescribed medication and 5 spoke no English.
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 ICD–10 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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View this table: [in a new window] | Table 1 Comparison of participants and non-participants |
Ratings and predictors of incapacity
Of the participants, 49 (43.8%) (95% CI 34.6–54.0) lacked
treatment-related decisional capacity, based on a judgement guided by the
MacCAT–T 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 African–Caribbean. 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 SAI–E. 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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View this table: [in a new window] | Table 2 Comparison of individuals with and without mental capacity to make a treatment decision |
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
1.10–5.05), but this became considerably smaller once diagnosis was
controlled for (OR=1.59, 95% CI 0.68–3.68), and was eradicated when
country of birth and diagnosis were controlled for simultaneously (OR=1.11,
95% CI 0.41–3.04). 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 African–Caribbean ethnic group
and lack of mental capacity (OR=9.75, 95% CI 1.07–89.2). This was
reduced, although not eradicated, by controlling for diagnosis (OR=5.81, 95%
CI 0.61–55.4). 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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View this table: [in a new window] | Table 3 Associations between psychopathology and lack of capacity |
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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View this table: [in a new window] | Table 4 Comparison of detained patients with capacity and voluntarily admitted patients with capacity |
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This study suggests that lack of treatment-related decisional capacity is common, but by no means inevitable, among adult psychiatric patients who are unwell enough to require in-patient admission. Our reported prevalence of 43.8% relates closely to an estimated 40% of acutely ill medical patients who were found to lack capacity in a recent study by this group in the same geographical area (Raymont et al, 2004). In a smaller study looking at treatment-related decisional capacity in psychiatric patients, only 20% of participants were judged to lack the capacity to consent to treatment (Bellhouse et al, 2003). Socio-demographic and clinical differences may partly explain this disparity: the present study was undertaken in a more deprived, ethnically diverse inner-city area, where a higher proportion of admissions are under the Mental Health Act 1983, than the previous study. The current estimate is likely to be conservative. Fifty-two per cent of the admitted patients were not included and, although there were few other differences between participants and non-participants, admission under the Mental Health Act 1983 and having a psychotic illness were both more common among the latter. Since we have shown that these two factors are associated with mental incapacity, it is almost certain that the true prevalence of incapacity is higher.
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 African–Caribbean 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 MacCAT–T 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
MacCAT–T 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 patient’s 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 Committee’s 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
- A small minority of patients with treatment-related decisional capacity
were detained under the Mental Health Act 1983.
- The majority of patients judged incapable of making a treatment decision
had poor insight and either a psychotic illness or bipolar affective
disorder.
- Further research is required to validate and improve our understanding of
the effect of ethnicity on mental capacity.
LIMITATIONS
- Fifty-two per cent of admittedpatients could not be included in the study;
had they been, the prevalence of incapacity would probably have been
higher.
- The study was based in an inner-London in-patient unit, which may limit the
generalisability of the findings.
- The association between cognitive impairment and incapacity may have been
inadequately assessed.
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Related articles in BJP:
- Highlights of this issue
- KIMBERLIE DEAN
BJP 2005 187: 301-a13.[Full Text] - Reliability of mental capacity assessments in psychiatric in-patients
- RUTH CAIRNS, CLEMENTINE MADDOCK, ALEC BUCHANAN, ANTHONY S. DAVID, PETER HAYWARD, GENEVRA RICHARDSON, GEORGE SZMUKLER, and MATTHEW HOTOPF
BJP 2005 187: 372-378.[Abstract] [Full Text]
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 S. Ripley, S. Jones, and A. Macdonald Capacity assessments on medical in-patients referred to social workers for care home placement Psychiatr. Bull., February 1, 2008; 32(2): 56 - 59. [Abstract] [Full Text] [PDF]
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 T. Calton, M. Ferriter, N. Huband, and H. Spandler A Systematic Review of the Soteria Paradigm for the Treatment of People Diagnosed With Schizophrenia Schizophr Bull, January 1, 2008; 34(1): 181 - 192. [Abstract] [Full Text] [PDF]
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 P. S. Appelbaum Assessment of Patients' Competence to Consent to Treatment N. Engl. J. Med., November 1, 2007; 357(18): 1834 - 1840. [Full Text] [PDF]
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 B. Parsons and M. Kennedy A review of recorded information given to patients starting to take clozapine and the development of guidelines on disclosure, a key component of informed consent J. Med. Ethics, October 1, 2007; 33(10): 564 - 567. [Abstract] [Full Text] [PDF]
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 D. OKAI, G. OWEN, H. McGUIRE, S. SINGH, R. CHURCHILL, and M. HOTOPF Mental capacity in psychiatric patients: Systematic review The British Journal of Psychiatry, October 1, 2007; 191(4): 291 - 297. [Abstract] [Full Text] [PDF]
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P. TYRER The British Journal of Psychiatry, October 1, 2007; 191(4): 372 - 372. [Full Text] [PDF]
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M. Church and S. Watts Assessment of mental capacity: a flow chart guide Psychiatr. Bull., August 1, 2007; 31(8): 304 - 307. [Full Text] [PDF]
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S. Y. H. Kim, P. S. Appelbaum, J. Swan, T. S. Stroup, J. P. McEvoy, D. C. Goff, D. V. Jeste, J. S. Lamberti, A. Leibovici, and E. D. Caine Determining when impairment constitutes incapacity for informed consent in schizophrenia research The British Journal of Psychiatry, July 1, 2007; 191(1): 38 - 43. [Abstract] [Full Text] [PDF]
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D. Claassen Financial incentives for antipsychotic depot medication: ethical issues J. Med. Ethics, April 1, 2007; 33(4): 189 - 193. [Abstract] [Full Text] [PDF]
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J. Beckett and R. Chaplin Capacity to consent to treatment in patients with acute mania Psychiatr. Bull., November 1, 2006; 30(11): 419 - 422. [Abstract] [Full Text] [PDF]
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D. Chiswick test of capacity has little practical benefit BMJ, December 17, 2005; 331(7530): 1469 - 1470. [Full Text] [PDF]
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eLetters:
Read all eLetters
- MENTAL RETARDATION - YET ANOTHER ISSUE IN MENTAL CAPACITY TO CONSENT
- Yatan PS Balhara, et al.
- BJP Online, 18 Nov 2005 [Full text]
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