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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 101-104

Assessment of mental capacity in psychiatric inpatients


Department of Psychiatry, Asha Hospital, Hyderabad, Telangana, India

Date of Submission01-Jun-2021
Date of Decision05-Aug-2021
Date of Acceptance10-Aug-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Dr. Isha Ahluwalia
ASHA Hospital, Road No. 14, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjp.tjp_25_21

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  Abstract 


Background: As per the Mental Health Care Act (MHCA) 2017, the construct of mental capacity assessment aims to define an individual's ability to make autonomous decisions. It provides a legal framework for mental health professionals to assess a person's ability to make treatment-related decisions. The present study aims to assess the mental capacity in psychiatric inpatients and various capacity variables affected in patients with psychosis.
Objective: The objective of this study is to assess mental capacity in a psychiatric inpatient facility.
Materials and Methods: It is a cross-sectional, observational study of 48 patients admitted to the psychiatric inpatient facility. MacArthur Competence Assessment Tool for Treatment interview was used to assess the capacity of participants. Data were analyzed using MS Excel version 2007.
Results: Out of 48 patients, we found that 41 (85.41%) patients were lacking mental capacity. Patients who scored poorly in the domain of “understand” also had poor performance on the rest of the domains, while those who had better understanding performed relatively well in other domains.
Conclusions: Under the MHCA 2017, mental capacity assessment has been included in alignment with UNCRPD 2006, to safeguard the interests of patients and help in effective policy-making. It is, therefore, important to incorporate mental capacity assessment in clinical practice to protect the rights of patients.

Keywords: Autonomy, capacity assessment, mental capacity, Mental Health Care Act


How to cite this article:
Ahluwalia I, Siddiqui NS, Kondepi S, Chandrasekhar K. Assessment of mental capacity in psychiatric inpatients. Telangana J Psychiatry 2021;7:101-4

How to cite this URL:
Ahluwalia I, Siddiqui NS, Kondepi S, Chandrasekhar K. Assessment of mental capacity in psychiatric inpatients. Telangana J Psychiatry [serial online] 2021 [cited 2022 Jan 17];7:101-4. Available from: http://www.:tjpipstsb.org/text.asp?2021/7/2/101/335637




  Introduction Top


Mental capacity is a multidimensional construct which defines individual ability to make autonomous decisions.[1] It is determined by the several factors such as understanding information, appreciation, i.e. retain and weigh information, ability to reason based on the received information, and to be able to make/express a choice based on relevant and adequate information.[2] Mental capacity is a continuous quality, and therefore, subject to change over a period of time. It is important to assess and reassess the construct and modify the decision based on a patient's capacity to consent.[3] Capacity in Mental Health Care Act (MHCA) 2017 refers to the capacity for mental health care (Section 4 of MHCA, Chapter 2).[4]

The assessment of a patient's mental capacity to make decisions is an intrinsic aspect of every physician-patient relationship. In psychiatry, a patient whose capacity is impaired is mainly seen in emergencies, high dependency units, and inpatient units.[5] The severity of symptoms, presence of psychosis, involuntary admission, and treatment refusal are the strongest risk factors for incapacity.[1]

Evidence from several studies and reviews suggest that approximately 40%–60%[6] of the persons with severe psychiatric disorders presenting to the emergency facility may lack capacity during admissions, however presuming incapacity/capacity may lead to violation of person's right to make their treatment-related decisions.

Until the last decade, under conventional mental health legislation, decision-making capacity had a minimal role in the initiation of treatment and involuntary psychiatric treatment.[7] Most countries earlier relied on”'Status approach” which is based on the fact of disability associated with mental illness. It does not provide an individual with mental illness enough autonomy to make decisions pertaining to illness. The concept of “Capacity” came into force into mental health legislation after engagement with UNCRPD 2006 (Article 12) leading to a proposition of “fusion approach.”[8] This approach aims to assess capacity in keeping with the autonomy and best interests of a person with mental illness (PMI). Hence, it eliminates the discrimination and formulates a law to enable the decision-making capability of individuals with special needs of different groups.[7] The key principle behind the concept of mental capacity assessment is to resolve the discrepancy between clinical presumptions about mental capacity when compared to the actual capacity.[9]

MHCA 2017 which is aligned with UNCRPD guidelines, included capacity assessment for admissions and treatment of PMI in mental health establishments. This can lead to a major shift in the attitude of professionals during admissions and treatment procedures which need to be done taking into account the mental capacity of PMI. The research and evidence for capacity assessment in clinical practice are still very scarce.

This study aims to assess mental capacity in patients admitted in psychiatric inpatient facility and time required to engage patients in the structured assessment of mental capacity. It also aims to study various capacity-related variables in the patient group with severe psychiatric illness.

Aims

  1. To assess mental capacity in a psychiatric inpatient facility
  2. To study the sociodemographic and capacity-related variables in individuals undergoing capacity assessment.



  Materials and Methods Top


This is an observational, cross-sectional study conducted in patients admitted from the emergency of a private psychiatric hospital at Hyderabad. Forty-eight consecutive participants diagnosed with mental illness as defined in MHCA 2017 admitted during a period of 3 months duration were assessed with a two-stage capacity test. The tool used to assess the capacity was MacArthur Competence Assessment Tool for Treatment (MacCAT-T). The MacCAT-T interview is used to guide the clinician to obtain information about a patient that is relevant for judgments about the patient's competence to consent or to refuse treatment. The interview evaluated four areas to determine the capacity of an individual: Understanding, Appreciation, Reasoning, Expressing a choice.

Inclusion criteria

  1. Patients aged between 18 and 60 years and admitted at Asha Hospital
  2. Satisfy the definition of PMI as defined in MHCA 2017
  3. Patient or his/her legally acceptable relative gives consent for the assessment.


Exclusion criteria

  1. Patients aged <18 years or more than 60 years
  2. Patient or their legally acceptable relatives who did not give consent for the assessment.


The data were collected after approval from the ethics committee review board. The participants were studied on sociodemographic characteristics and various domains of the MacCAT-T interview scale. Data were analyzed in MS-Excel version 2007 by calculating mean, standard deviations, and proportions for various categories.


  Results Top


Main outcome measures

Forty-eight psychiatric admissions aged between 18 and 60 years were identified during the study. [Table 1] and [Table 2] show the sociodemographic characteristics of the study population. Capacity assessments were carried out for capacity to consent for admissions and treatment. The time required to perform a structural assessment is given in [Table 3], while different capacity related variables are mentioned in [Table 4].
Table 1: Agewise mental capacity

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Table 2: Genderwise Mental capacity

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Table 3: Assessment of capacity after admission (days)

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Table 4: Proportions of MacArthur Competence Assessment Tool variables

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Outcomes

[Overall 41 (87.5%) admissions assessed for mental capacity were found to lack capacity. Only 7 patients had capacity as per MHCA 2017 (all 4 domains of assessment must be present). The proportion of admission with a varying diagnosis is shown in [Table 5]] with the highest prevalence of incapacity in schizophrenia spectrum disorders. [Table 3] shows the proportion in days after admission when a detailed structural assessment was possible.
Table 5: Association of mental capacity with diagnosis

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Sociodemographic characteristics

Above [Figure 1], indicates that if understanding is poor it is unlikely that patient will have mental capacity and patients might score poorly on other abilities.
Figure 1: Effect of understanding on other MaCCAT-T variables

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  Discussion Top


As per MHCA 2017, it is crucial to assess mental capacity for an individual before the provision of any mental health care. The capacity tends to vary across specific domains and specific times, as it is a continuum in quality. Mental capacity is also of legal relevance as it involves decisions regarding admissions and obtaining treatment of various modalities. The act usually aims to assess capacity before starting treatment/admissions/advanced directives and serially over time to safeguard the autonomy of an individual.[10] This study attempts to observe and assess the mental capacity in 48 in-patients admitted from emergency under section 89 of MHCA 2017.[11]

The frequency of incapacity among those tested was approximately 85.41%. These findings were slightly higher than those in previous studies. In one of the systematic review by Okai et al.,[1] 37 papers were reviewed; wherein heterogeneous results were obtained, however median incapacity was around 29%. In some studies, such as, (Owen et al)[1] majority of patients were voluntary participants, who had insight into their disorder, therefore capacity was present. Other studies where patients were admitted involuntarily, incapacity was seen as high as 40%–60% (Appelbaum PS et al).[9],[12]

The findings of sociodemographic characteristics such as age and gender were in line with previous studies and no association with mental capacity was noted. Mental capacity is not associated with any sociodemographic variable except advancing age, which is mainly attributed to cognitive decline and increased negative symptoms in older patients with psychotic illness.[1] Majority of the patients admitted from emergency had psychotic disorder (either primary or secondary); therefore, findings across various diagnosis in [Table 5], suggest incapacity in a majority of sample population.

We assessed the number of days after which it was possible to engage the patients in structural assessment and their outcomes. The detailed structural assessment could be performed between 3 and 10 days after admission for the majority of inpatients. However, mental capacity was lacking in most of these patients in the first 2 weeks of admission.

It is of utmost importance to understand provided information to further process it for making treatment relevant decisions. Therefore, we divided participants based on understanding (good/poor) and studied remaining variables in association with the former. Our findings suggested that the majority of the patients with poor understanding were lacking in appreciation and reasoning variables of MacCAT-T as well. Previous studies in this context by Owen et al. and Spencer et al. also had similar outcomes.[12],[13]

Strengths

Although MHCA 2017 has been put in practice in our country, there is no available data or research on the assessment of mental health capacity in the Indian population. Our study puts out a cross-section of patients admitted through emergency and their incapacity in decision-making, suggesting higher possibilities of legal implications unless basic capacity assessments are done. We could also branch out the capacity variables and study their role in decision-making domains.

Limitations

The sample is too small to generalize to the general population with mental health needs. We have taken account of patients that visited emergency services and those with severe mental illness. It will be more comprehensive to study in all patients presenting to psychiatric facility both inpatients and outpatients. Further studies should also assess mental capacity for different domains such as for advanced directives and performing procedures such as electroconvulsive therapy. It will also be beneficial to assess mental capacity at frequent intervals during hospitalization to understand the legal implications of involuntary versus voluntary hospitalization and decision-making for discharge procedures.

[TAG:2]Conclusions[/TAG:2]

Introduction of MHCA 2017 promises to provide patient-centered treatment approach and provides autonomy to make decisions regarding their mental health care. Assessment of mental capacity, although a part of the mental health act still not completely incorporated into clinical practice. This provision will help to safeguard the interests and protect patient's rights.[2] This mental health legislation which is aligned with UNCRPD 2006 aims at protecting patient's rights.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Okai D, Owen G, McGuire H, Singh S, Churchill R, Hotopf M. Mental capacity in psychiatric patients: Systematic review. Br J Psychiatry 2007;191:291-7.  Back to cited text no. 1
    
2.
Tiwari S, Pandey N. Need for mental capacity act and its assessment in India. J Geriatr Ment Health 2014;1:79-82.  Back to cited text no. 2
  [Full text]  
3.
Buchanan A. Mental capacity, legal competence and consent to treatment. J R Soc Med 2004;97:415-20.  Back to cited text no. 3
    
4.
Namboodiri V. Capacity for mental healthcare decisions under the mental healthcare act. Indian J Psychiatry 2019;61:S676-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med 2007;357:1834-40.  Back to cited text no. 5
    
6.
Cairns R, Maddock C, Buchanan A, David AS, Hayward P, Richardson G, et al. Prevalence and predictors of mental incapacity in psychiatric in-patients. Br J Psychiatry 2005;187:379-85.  Back to cited text no. 6
    
7.
Szmukler G, Kelly BD. We should replace conventional mental health law with capacity-based law. Br J Psychiatry 2016;209:449-53.  Back to cited text no. 7
    
8.
Brown PF, Tulloch AD, Mackenzie C, Owen GS, Szmukler G, Hotopf M. Assessments of mental capacity in psychiatric inpatients: A retrospective cohort study. BMC Psychiatry 2013;13:115.  Back to cited text no. 8
    
9.
Math S, Moirangthem S, Krishna K, Reddi V. Capacity to consent in mental health care bill 2013: A critique. Indian J Soc Psychiatry 2015;31:112-8.  Back to cited text no. 9
  [Full text]  
10.
Owen GS, Szmukler G, Richardson G, David AS, Raymont V, Freyenhagen F, et al. Decision-making capacity for treatment in psychiatric and medical in-patients: Cross-sectional, comparative study. Br J Psychiatry 2013;203:461-7.  Back to cited text no. 10
    
11.
Spencer BW, Gergel T, Hotopf M, Owen GS. Unwell in hospital but not incapable: Cross-sectional study on the dissociation of decision-making capacity for treatment and research in in-patients with schizophrenia and related psychoses. Br J Psychiatry 2018;213:484-9.  Back to cited text no. 11
    
12.
Ministry of Law and Justice. The Mental Healthcare Act. No.10 of 2017 Gazzette of India; 2017.  Back to cited text no. 12
    
13.
United Nations Convention on the Rights of Persons with Disabilities; 2006.  Back to cited text no. 13
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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