title: Functional mental capacity, treatment as usual and time: magnitude of change in secure hospital patients with major mental illness.
abstract: BACKGROUND
  Decision making ability can change with time, depending on mental or physical health. Little is known about the factors that determine this change and the relationship of capacity to time. As a pilot for studies using functional mental capacities as an outcome measure, we sought to quantify this relationship measuring change over time using competence assessment tools, and rating scales for symptoms and global function.
  
  
  METHODS
  We assessed 37 inpatients in a secure psychiatric hospital. All patients met the diagnostic and statistical manual of mental disorders-fourth edition and International classification of diseases, 10th edition criteria for an Axis 1 mental illness, all with psychosis. Patients were interviewed twice a mean of 323 days apart (median 176 days range 17-1221 days). The MacArthur competence assessment tools for consent to treatment (MacCAT-T) and fitness to plead (MacCAT-FP) were used to quantify functional capacity along with the Positive and Negative Syndrome Scale (PANSS) and global assessment of function (GAF) scale. A comparison was also made between those patients prescribed clozapine in comparison to other antipsychotics.
  
  
  RESULTS
  The number judged by treating psychiatrists to lack capacity either to make a treatment choice or to plead in court fell from 35 to 8%. Change was greatest for those admitted within the previous 9 months. The measures of capacity improved between time 1 and time 2 for both consent to treatment and fitness to plead. The measures of capacity improved with positive symptoms within the PANSS and with GAF scores. Those with shorter lengths of stay at baseline had the greatest improvements in the MacCAT-FP scores. Effect sizes were medium or large (0.3-0.7+). As expected, patients prescribed clozapine had larger changes in functional mental capacities and larger effect sizes than those prescribed other psychotropics. The results show a strong relationship between the clinicians' assessment of capacity and structured rating scales.
  
  
  CONCLUSIONS
  We have shown that there is an improvement in capacity scores with time. More research is needed to compare the effect of treatment on capacity at fixed time intervals. It would also be helpful to look at a more general patient population.
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland. julieanne.dornan@hse.ie.|Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. julieanne.dornan@hse.ie.
authors.forename: Julieanne
authors.initials: J
authors.lastname: Dornan
authors.affiliation: St Patricks Hospital, Dublin, Ireland. mkennedy@stpatsmail.com.|Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. mkennedy@stpatsmail.com.
authors.forename: Miriam
authors.initials: M
authors.lastname: Kennedy
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland. garlandjac@yahoo.co.uk.
authors.forename: Jackie
authors.initials: J
authors.lastname: Garland
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland. emerrutledge@yahoo.ie.|Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. emerrutledge@yahoo.ie.
authors.forename: Emer
authors.initials: E
authors.lastname: Rutledge
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland. kennedh@tcd.ie.|Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. kennedh@tcd.ie.
authors.forename: Harry G
authors.initials: HG
authors.lastname: Kennedy
mesh_terms: D000328:Adult; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D003024:Clozapine / Q000627:therapeutic use*; D005260:Female; D005555:Forensic Psychiatry; D006760:Hospitalization; D006778:Hospitals, Psychiatric; D006801:Humans; D007258:Informed Consent; D007297:Inpatients; D008297:Male; D016743:Mental Competency / Q000523:psychology*; D008875:Middle Aged; D010865:Pilot Projects; D011569:Psychiatric Status Rating Scales; D011618:Psychotic Disorders / Q000175:diagnosis* / Q000188:drug therapy / Q000503:physiopathology / Q000523:psychology; D013997:Time Factors
chemical_list: D014150:Antipsychotic Agents; D003024:Clozapine