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RESEARCH: Gareth S Owen, Genevra Richardson, Anthony S David, George Szmukler, Peter Hayward, and Matthew Hotopf Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study BMJ 2008; 337: a448 [Abstract] [Full text]

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Treatment for mental illness: Who decides?

Sahoo Saddichha   (6 July 2008)

Mental capacity, a dynamic process:

Ignasi Agell, Nitin Gupta   (9 July 2008)

Assessment and Interpretation of Mental Capacity is indeed a Complex Process!

Nitin Gupta, Ignasi Agell   (10 July 2008)

Trustwide Audit on Mental Capacity assessment and documentation

GAURAV MEHTA, Alex Phipps ,FY2 Psychiatry ,Department of Liaison Psychiatry, North East London Mental Health NHS Trust E11 1NR   (10 July 2008)

Mental Capacity, diagnosis and insight

Matthew Hotopf, Gareth S Owen, Anthony S David, Genevra Richardson   (16 July 2008)

Presuming mental capacity and admission

Rajeswari Venkatesan   (4 August 2008)

Specifying Decisions

Matthew Hotopf, Gareth S Owen   (7 August 2008)

Treatment for mental illness: Who decides? 6 July 2008
Sahoo Saddichha, Senior Consultant (WHO-BGI) Kolkata, India Send response to journal: Re: Treatment for mental illness: Who decides?	This article by Owen and colleagues [1] has again stoked the controversy of who decides whether a person with mental illness should be treated or not. On the basis of rights of the mentally ill, every person should be able to deny taking treatment. But, mental illness is not like any other illness since insight into the illness is the first to be affected with the onset of illness.One can very easily verify this with high levels of incapacity observed in all the forms of psychiatric illness where insight is poor, viz., schizophrenia, psychotic illness and bipolar manic disorder. Again, once insight is affected, so is judgement. Then who actually decides whether the person ought to be treated or not? As the authors themselves say, the answers are too complicated although the questions may be simple. Some other observations on the study need to be mentioned. Although the authors have quoted references [2-5] for the inter-rater reliability of the MacArthur competence assessment tool, these are only for the original scale and not for the modified version as was used by the authors. Further, i do not understand why only about 50% of the subjects were assessed using this tool and the others by interview? What then would be the validity of the interview? I would also like to draw attention to the diagnosis of "psychotic illness" as mentioned in Table 2. To the best of my knowledge, no such diagnosis exists in ICD 10. References: 1) 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;448- doi:10.1136/bmj.39580.546597.BE 2)Okai D, Owen G, McGuireH, Singh S, Churchill R, HotopfM. Mental capacity in psychiatric patients: systematic review. Br J Psychiatry 2007;191:291-7. 3) Grisso T, Applebaum PS, Hill-Fotouhi C. TheMacCAT-T: A clinical tool to assess patients’ capacities to make treatment decisions. Psychiatr Serv 1997;48:1415-9. 4) Applebaum PS. Assessment of patient’s competence to consent to treatment. N Engl JMed 2007;357:1834-40. 5) Cairns R,Maddock C,David AS,Hayward ,Richardson G, Szmukler G,et al. Reliability of mental capacity assessments in psychiatric inpatients. Br J Psychiatry 2005;187:372-8. Competing interests: None declared
Mental capacity, a dynamic process: 9 July 2008
Ignasi Agell, Consultant Psychiatrist, South Staffordshire and Shropshire Healthcare NHS Foundation Trust Cherry Orchard House, 35 Hospital Street, Tamworth, B79 7EE, Nitin Gupta Send response to journal: Re: Mental capacity, a dynamic process:	Owen et al conclude that mental incapacity, to make decisions on treatment, is common in people admitted to psychiatric wards from the community(1). We feel the study was important and relevant but the results may not be clinically accurate in today’s practice. As the study was completed in England and the Mental Capacity Act (MCA) 2005(2) is already in place, we feel that the principles of the MCA should apply. The Code of Practice (3) provides guidelines for the application of the MCA. It states that “a person that lacks capacity means a person who lacks capacity to make a particular decision or take a particular action for themselves at the time the decision or action needs to be taken” (3). However, patients in the study were assessed on the basis of decisions that had already been made, albeit in the very recent past, regarding treatment or admission into hospital. Even if we considered that the decision was yet to be made or seen as a decision to agree to continue with the same treatment plan, the Code of Practice clearly says that before concluding that an individual lacks capacity, it is important to take all possible steps to try to help them reach a decision(3). The Code also highlights the importance in mental health of using the Care Programme Approach and the role of the care-coordinator to further assist with the assessment; facts that are not taken into account in either the design or interpretation of the results in this study. Assessment of capacity should be seen as a dynamic assessment rather than a one of isolated assessment. We also want to comment on the use of “psychotic disorder” as diagnosis belonging to the 10th edition of the International Classification of Diseases (ICD-10) (4) in table 2 of the article. This is not a diagnosis under ICD-10 and the numbers “N” do not correlate with the results and diagnoses given in table 1, unless they consider all cases with organic brain syndromes and “other” diagnoses under the umbrella term of “psychotic disorder”. We are left uncertain regarding the effect of the use of alcohol and other substances on capacity as results are not given in relation to the use or misuse of substances, although the data was recorded to that effect and is a relevant clinical issue. Nevertheless, we do appreciate the timely publication of this complicated issue from a research perspective which hopefully will lead to further understanding of the difficulties, as stated by the authors, of using two legal frameworks based on different principles. References: 1) Owen GS, Richardson G, David AS, Smukler G, Hayward P, Hotopf M. Mental capacity to make decissions on treatment in people admitted to psychiatric hospitals: cross sectional study. BMJ 2008; 337; 448- doi10.1136/bmj.39580.546597.BE 2) Department of Health. Mental Capacity Act. London: Stationery Office, 2005. 3) Mental Capacity Act 2005. Code of practice. Norwich: Stationery Office, 2007. 4) World Health Organization (1992) Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10). Geneva: WHO. Competing interests: None declared
Assessment and Interpretation of Mental Capacity is indeed a Complex Process! 10 July 2008
Nitin Gupta, Consultant Psychiatrist Margaret Stanhope Centre-South Staffordshire & Shropshire Healthcare NHS Foundation Trust, DE13 0RB, Ignasi Agell Send response to journal: Re: Assessment and Interpretation of Mental Capacity is indeed a Complex Process!	We would like to highlight some conceptual issues related to the areas addressed in the study by Owen et al (1). They discuss about the “mental capacity to make decisions on treatment in people admitted to psychiatric hospitals”. The decisions were clarified into 3 main categories i.e. stabilization with drugs, admission to a place of safety, admission for assessment. There are two conceptual difficulties with the interpretation of this approach- [a] the clinical researcher clarified about the main decision on treatment. However, it is not uncommon in the clinical setting that any of the three categories may co-exist. Hence it would have been useful to understand as to how was the main decision arrived at- by subjective clinical opinion or using objective documentation in case notes? [b] Also, being admitted to a place of safety or for assessment does not necessarily translate into actual treatment being provided to the patient. Hence, in our opinion, it may have been more appropriate to the title of the article being “mental capacity in people to make decisions on inpatient stay in psychiatric hospitals”. The authors attempted to assess capacity as close to admission as possible (median = 2 days; range = 0-8 days). As mentioned elsewhere in this issue by Dawson (2), lack of capacity can be quite prevalent just immediately after admission and would tend to improve/fluctuate over the continued period of stay. It may have been worthwhile to provide further sub- analysis on lack of capacity for each of the main categories, as this could be relevant in people who are admitted for assessment and place of safety (keeping in mind the high number of people with recent alcohol/substance abuse). Under methodology, it is mentioned that written consent was obtained. We know that assessment of capacity is task-specific. Hence, it is interesting to note that whilst the sample had low (40%) prevalence of mental capacity for being admitted to a psychiatric hospital (in our opinion-a relatively less complex decision making process), yet apparently 100% demonstrated mental capacity related to the highly complex process of obtaining consent for research. A major concern is related to the research design wherein psychiatric trainees undertook mental capacity (MC) assessments. Although Owen et al (1) clarify the trainees were given information on assessment of MC and received a one hour training session, yet it is widely acknowledged that assessing capacity is not the simplest of clinical tasks (with potential legal ramifications). Certain queries spring to mind i.e. were all trainees in a psychiatry rotation or were some foundation year doctors (as this can impact upon levels of experience and competence)? Also, a major weakness (due to lack of information so provided) is the lack of any evidence indicating attempts at ongoing supervision OR establishing inter- rater reliability between the 10 trainees, or between the trainee(s) and researcher, or trainee(s) and the investigator. Additionally, there is no mention about the questions and/or principles followed in assessing MC (though we acknowledge mention of the basic framework of the four abilities related to disclosure). We mention this aspect as it is linked with, and reiterates, our earlier concern. We fully agree with the authors that navigating the two different frameworks of Mental Capacity Act (MCA) and Mental Health Act is likely to be complicated. But, we would like to address this issue of capacity for psychiatric in-patients in further detail and broaden the scope of debate. If assessment of MC is to be core part of a psychiatric assessment, ideally when should it be done; how frequently should it be carried out; who should be ideally doing it; how to ensure adequate training in order to ensure competent assessments (and decisions thereof); how to handle a difference of opinion regarding capacity by different professionals (e.g. psychiatric trainee, nurse, social worker) of the same care team keeping in mind that anybody is deemed competent to assess MC under MCA; which clinical framework to follow in a busy clinical setting (e.g. an acute, adult psychiatric unit)? Can the psychiatric trainee’s (or for that matter - a nursing or social worker or psychologist colleagues’) assessment be valid enough to stand the medico-legal test for the Consultant/Responsible Medical Officer of that particular patient (as per the concept of ‘New Ways of Working’)? However, this study has its strengths too and we hope that it leads to generation of a robust debate and further thoughts on future management of the complex yet intriguing issues subsumed under the two conceptually different statutory acts. REFERENCES: (1) Owen GS, Richardson G, David AS, Smukler G, Hayward P, Hotopf M. Mental capacity to make decissions on treatment in people admitted to psychiatric hospitals: cross sectional study. BMJ 2008; 337: 448- doi10.1136/bmj.39580.546597.BE (2) Dawson, J. Mental capacity and psychiatric admission. BMJ 2008; 337:a116, doi: 10.1136/bmj.a116 Competing interests: None declared
Trustwide Audit on Mental Capacity assessment and documentation 10 July 2008
GAURAV MEHTA, FTSTA-ST2 Psychiatry Department of Liaison Psychiatry, North East London Mental Health NHS Trust E11 1NR, Alex Phipps ,FY2 Psychiatry ,Department of Liaison Psychiatry, North East London Mental Health NHS Trust E11 1NR Send response to journal: Re: Trustwide Audit on Mental Capacity assessment and documentation	Dear sir, We read with interest this article alongwith the editorial on Mental Capacity this week. Following the Mental Capacity Act 2005 (implemented in April 2007), the authors carried out a trustwide audit into Mental Capacity Assessment & Documentation in North East London Mental Health Trust during September-November 2007.The standard used for the audit purpose was that the Mental Capacity assessment should be carried out thoroughly based on all the domains as mentioned in the Mental Capacity Act 2005. This information should be recorded in the patient’s notes. Method The audit looked at 50 patients across the Trust, distributed equally between male and female and across all client groups including some in the community. It also covered all age groups, but with a slight preponderance of over 65s. The auditors targeted patients where capacity was felt to be an issue and either lacking or borderline. Results In 74% of cases(37 out of 50) where capacity was an issue, there was no documented assessment in the clinical notes. In the 13 instances where there was such documentation, in 31%of patients the statutory test from the MCA was either not used at all or incompletely used. In 75% of the 4 cases where IMCA criteria were met the referral was made. There was no evidence of advance decisions or Lasting Power of Attorney. There were no cases where patients were felt to be deprived of liberty. Conclusions & Recommendations • The procedure of determining Mental Capacity requires a formal assessment to be carried out in specified circumstances as recommended. This should be clearly recorded in notes • The North East London Mental Health Trust is due to issue a new procedure to formalise the assessment of mental capacity in set circumstances. Reference http://www.bma.org.uk/ap.nsf/Content/mencapact05?OpenDocument&Highlight=2,mental,capacity Competing interests: None declared
Mental Capacity, diagnosis and insight 16 July 2008
Matthew Hotopf, Professor of General Hospital Psychiatry Department of Psychological Medicine, Institute of Psychiatry, London SE5 9RJ, Gareth S Owen, Anthony S David, Genevra Richardson Send response to journal: Re: Mental Capacity, diagnosis and insight	We thank Dr Saddicha for drawing attention to the issue of insight and capacity - a topic which will be the subject of an upcoming paper analysing our data further. The issue is complicated because insight is not a legal concept yet sometimes does legal 'work'. In some ways legal capacity already recognises poor insight via its recognition that inability to 'appreciate' (in US jurisdictions) or 'use' (in English Mental Capacity Act 2005) relevant information in making a decision can threaten decisional capacity. We agree that the law of consent would benefit from a richer understanding of insight as it applies to psychosis and mania. Most conceptual work on insight has been limited to psychotic illness and mania (Amador and David, 2004). Mental capacity is broader. Saddichha asserts that insight into illness is the first thing to be affected with the onset of mental illness. Our research does not support such a global claim and this area needs more careful analysis. In an earlier paper (Cairns et al, 2005) we showed that insight was the aspect of psychopathology most strongly associated with lack of capacity, but the association is not absolute - it is possible to have insight and lack capacity and vice versa. The modified version of the competence assessment tool (MacCAT-T) we used applied to a hospitalisation decision and had an identical structure to a medication decision - only the disclosed information changed. The MacCAT-T is a tool to assist a clinical judgement about the capacity for a decision and reliability has been tested in the way we used it (Cairns et. al., 2005). Space limited the amount we could describe non participants but we used the interviews by psychiatric trainees (ward doctors) to gain more information on non-participants so as to estimate the prevalence of capacity in the whole sample of consecutive admissions. This is considerably better than ignoring non-participants, and we gained sufficiently good aggreement between the clinical researcher and the psychiatric trainees (kappa 0.54) to assume that the trainee ratings had some value. Psychotic disorders are alive and well in ICD-10. Categories F20-29 includes categories such as nonorganic psychotic disorders and acute and transient psychotic disorders. It this group of headings (i.e. F20-29) which we meant by psychotic illness, which is a more concise description than ICD-10's heading of "schizophrenia, schizotypal and delusional disorders". Cairns, R. Maddock, C. Buchanan, A. David, A.S. Hayward, P. Richardson, G. Szmukler, G. Hotopf, M. Prevalence and predictors of mental incapacity in psychiatric in-patients. Br. J. Psychiatry 2005 187 379-85 Cairns R,Maddock C,David AS,Hayward ,Richardson G, Szmukler G,et al. Reliability of mental capacity assessments in psychiatric inpatients. Br J Psychiatry 2005;187:372-8. Amador XF & David AS (eds) (2004) Insight and Psychosis: awareness of illness in schizophrenia and related disorders (2nd ed). Oxford University Press, Oxford. Competing interests: as per our BMJ article
Presuming mental capacity and admission 4 August 2008
Rajeswari Venkatesan, Staff Grade Psychiatrist Lancashire Care NHS Trust Crisis Response and Home Treatment Team, Blackburn BB1 3BL Send response to journal: Re: Presuming mental capacity and admission	It was interesting to read Gareth S Owens’s 'Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals' and despite raising many questions it served as a good study on Mental capacity. I want to share my view on the capacity issue for the patients who are admitted informally as this study quotes around two fifths lack capacity.When patients admitted to psychiatric wards voluntarily, as psychiatrists we tend to underestimate their level of capacity especially when patients accept treatment. This might in turn have an impact on their needs. As we commonly encounter drug and alcohol patients in day to day practice it would have been interesting if the authors highlighted the incapacity rates for this group. But we need to appreciate the authors' effort to this study. Reference Gareth S Owen, Genevra Richardson, George Szmukler,Anthony S David, Peter Hayward, Matthew Hotopf, BMJ 2008;337:a448, doi: 10.1136/bmj.39580.546597.BE Competing interests: None declared
Specifying Decisions 7 August 2008
Matthew Hotopf, Professor of General Hospital Psychiatry SE5 9RJ, Gareth S Owen Send response to journal: Re: Specifying Decisions	It is excellent to see the responses to our article from practicing psychiatrists who now actually have to make capacity judgments under the new law. Issues surrounding mental capacity are multiple and our article addresses only a limited number of them. In this paper we only report data on prevalence of mental incapacity at the point of admission to psychiatric hospital using a sample that is as representative as we could make it. The study says nothing about best interests. The associations of incapacity, including drug and alcohol, will be reported in other papers we aim to publish shortly. Here we just try to map capacity onto the peri- admission period of acute general adult psychiatry and relate it to diagnoses and MHA 83 status. Gupta and Ignell raise a worry about whether our capacity assessments are valid because they took place after the decision had been made to admit and were unclearly specified - including admission to a place of safety which they say needn’t involve a specific treatment decision. We took any admission to hospital to be a treatment decision even if it involved no medication and specified it as such using the MacCAT structure. We considered this to be the decision at stake unless the medical record made it clear that the purpose of the admission was stabilization on medication for a documented illness. In that case we considered the bottom line decision to be medication and specified it using the MacCAT structure. Admission to hospital is an intervention that can easily be conceptualized as a treatment with its own risks and benefits. This is true regardless of whether medication is part of the plan. It is hard to think that a decision only faces a patient at the exact moment they are admitted – a hospitalization decision continues for as long as the patient faces an inpatient ward to be on or not be on. It is likewise with a serious medication decision. We specified decisions in this way because the capacity assessments are not very informative to practicing clinicians unless they relate to decisions which patients need to make rather than to hypothetical decisions or decisions upon not much rests. We are at the beginning of a process of getting our bearings in a new and complex legal landscape. We hope that this study helps but clearly more work needs to be done. Competing interests: None declared