title: Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study.
abstract: BACKGROUND
  Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients?
  
  
  OBJECTIVE
  To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice.
  
  
  METHODS
  A secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool - Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability.
  
  
  RESULTS
  Most people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P = 0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better 'test' of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P = 0.02).
  
  
  CONCLUSIONS
  Among those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting.
authors: Gareth S. Owen, PhD, MRCPsych, Department of Psychological Medicine, King's College London, Institute of Psychiatry, London, UK; George Szmukler, FRCPsych, Department of Health Service and Population Research, King's College London, Institute of Psychiatry, London, UK; Genevra Richardson, LLM FBA, School of Law, King's College London, UK; Anthony S. David, FRCPsych, Department of Psychological Medicine, King's College London, Institute of Psychiatry, London, UK; Vanessa Raymont, MRCPsych, Centre for Mental Health, Department of Medicine, Imperial College, London, UK, and Department of Radiology, Johns Hopkins University, USA; Fabian Freyenhagen, PhD, Wayne Martin, PhD, School of Philosophy and Art History, University of Essex, Wivenhoe Park, Essex, UK; Matthew Hotopf, PhD, MRCPsych, Department of Psychological Medicine, King's College London, Institute of Psychiatry, London, UK.
authors: Gareth S
authors: GS
authors: Owen
authors: George
authors: G
authors: Szmukler
authors: Genevra
authors: G
authors: Richardson
authors: Anthony S
authors: AS
authors: David
authors: Vanessa
authors: V
authors: Raymont
authors: Fabian
authors: F
authors: Freyenhagen
authors: Wayne
authors: W
authors: Martin
authors: Matthew
authors: M
authors: Hotopf
mesh_terms: D000208:Acute Disease; D000328:Adult; D003072:Cognition Disorders / Q000523:psychology; D032882:Comprehension; D003430:Cross-Sectional Studies; D003657:Decision Making; D005260:Female; D006769:Hospitals, General; D006778:Hospitals, Psychiatric; D006801:Humans; D007258:Informed Consent / Q000331:legislation & jurisprudence / Q000523:psychology*; D007297:Inpatients / Q000523:psychology*; D007406:Interview, Psychological; D008297:Male; D016743:Mental Competency / Q000331:legislation & jurisprudence / Q000523:psychology*; D028642:Persons with Psychiatric Disorders / Q000331:legislation & jurisprudence / Q000523:psychology; D008875:Middle Aged; D026684:Personal Autonomy; D012372:ROC Curve
references: Lancet. 2004 Oct 16-22;364(9443):1421-7
references: 15488217
references: Br J Psychiatry. 2009 Sep;195(3):257-63
references: 19721117
references: Am J Geriatr Psychiatry. 2002 Mar-Apr;10(2):151-65
references: 11925276
references: BMC Public Health. 2011 Nov 11;11:861
references: 22078667
references: Law Hum Behav. 1995 Apr;19(2):105-26
references: 11660290
references: Psychol Med. 2003 Nov;33(8):1463-71
references: 14672255
references: BMC Med Ethics. 2009 Sep 02;10:15
references: 19725954
references: Am J Geriatr Psychiatry. 2002 Mar-Apr;10(2):166-74
references: 11925277
references: Rutgers Law Rev. 1996 Winter;48(2):345-71
references: 16086484
references: Am J Psychiatry. 1995 Jul;152(7):1033-7
references: 7793439
references: Br J Psychiatry. 2007 Nov;191:453-4
references: 17978328
references: Psychosomatics. 2006 Jul-Aug;47(4):325-9
references: 16844891
references: Arch Neurol. 1995 Oct;52(10):955-9
references: 7575222
references: J Eval Clin Pract. 2012 Oct;18(5):1038-44
references: 22995005
references: J Psychiatr Res. 1975 Nov;12(3):189-98
references: 1202204
references: BMJ. 2008 Jun 30;337:a448
references: 18595931
references: Br J Psychiatry. 2005 Oct;187:372-8
references: 16199798
references: Br J Psychiatry. 2007 Oct;191:291-7
references: 17906238
references: Int J Law Psychiatry. 2007 Mar-Apr;30(2):112-7
references: 17141874
references: Am J Psychiatry. 1979 Sep;136(9):1121-7
references: 474799
references: Arch Gen Psychiatry. 1981 Mar;38(3):358-62
references: 7212968
references: Psychol Med. 2009 Aug;39(8):1389-98
references: 18940026