Mental capacity, diagnosis and insight in psychiatric in-patients: A cross-sectional study
Open accessAbstract
BACKGROUND: Mental capacity is now a core part of UK mental health law and clinicians will increasingly be expected to assess it. Because it is a legal concept there is a need to clarify associations with variables that clinicians are more familiar with, especially insight. METHOD: In this cross-sectional study we recruited consecutive psychiatric admissions to the Maudsley Hospital, London. We carried out structured assessments of decision making using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), resulting in a clinical judgement about capacity status. We analysed associations with a range of sociodemographic and clinical variables, including insight score on the Expanded Schedule for the Assessment of Insight (SAI-E). The same variables were compared in an analysis stratified according to diagnostic group: psychotic disorders/bipolar affective disorder (BPAD)/non-psychotic disorders. RESULTS: Psychotic disorders and manic episodes of BPAD are most strongly associated with incapacity. In such patients, insight is the best discriminator of capacity status. In patients with non-psychotic disorders, insight is less strongly associated with capacity; in this group depressed mood discriminates capacity status whereas it does not in psychotic disorders. Cognitive performance does not discriminate capacity status in patients with psychotic disorders. CONCLUSIONS: Mental capacity has complex relationships with psychopathological variables, and these relationships are different according to diagnostic group. Insight is the best discriminator of capacity status in psychotic disorders and BPAD but not in non-psychotic disorders.
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Another study found that being female predicted incapacity in a bivariate analysis, which became non-significant when adjusting for alcohol or substance dependence.
“Another study found that being female predicted incapacity in a bivariate analysis (OR = 0.19, 95% CI [1.07 -3.56]), which became nonsignificant when adjusting for alcohol or substance dependence (G.Owen et al., 2009).”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G.Owen et al., 2009
The Sociodemographic and basic clinical variables section reports an unadjusted association between female sex and incapacity that disappears after adjustment for alcohol or substance dependence. The citing sentence gives the unadjusted odds ratio as 0.19, but the paper reports 1.96 (95% CI 1.07–3.56). (LLM, conf=0.90)
Experimental — accuracy not yet measuredIn patients with a diagnosis of depression, poor insight was a poor predictor of incapacity and regaining capacity was less associated with change in insight.
“although in patients with a diagnosis of depression poor insight was a poor predictor of incapacity (G. S. Owen et al., 2008) and regaining capacity was less associated with change in insight (G.Owen et al., 2009).”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G.Owen et al., 2009
The Insight section reports that poor insight is less strongly associated with incapacity in non-psychotic disorders than in psychotic disorders or BPAD, and that it does not map cleanly onto capacity status in the non-psychotic group. That group includes unipolar depression, but the paper does not report this result for patients with depression alone. The separate statement about regaining capacity is attached to a different citation in the citing sentence. (LLM, conf=0.82)
Experimental — accuracy not yet measuredDepression was also associated with incapacity.
“and depression (G.Owen et al., 2009;G. S. Owen et al., 2008G. S. Owen et al., , 2011;;Tor et al., 2020).”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G.Owen et al., 2009
The Conclusions state that depression is associated with incapacity in non-psychotic disorders, a group dominated by unipolar depression. The claim omits that diagnostic qualifier: the Sociodemographic and basic clinical variables section reports an association between a depression diagnosis and retaining capacity overall. (LLM, conf=0.88)
Experimental — accuracy not yet measuredAcross inpatients, poor insight was a consistent and strong predictor of incapacity.
“Across inpatients, poor insight was also a consistent and strong predictor of incapacity (G.Owen et al., 2009;G. S. Owen et al., 2011;Seo et al., 2011;Skipworth et al., 2013;Spencer et al., 2018)”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G.Owen et al., 2009
Hallucinations were correlated with capacity in non-psychotic disorders, but not in psychotic disorders.
“Hallucinations were correlated with capacity in non-psychotic disorders (G.Owen et al., 2009), but not in psychotic disorders (Skipworth et al., 2013;Spencer et al., 2018).”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G.Owen et al., 2009
Bipolar affective disorder of the manic type was the next diagnosis associated with high rates of incapacity.
“followed by bipolar affective disorder (BPAD) of the manic type (Chiu et al., 2014;Mandarelli et al., 2018b;G. Owen et al., 2009;G. S. Owen et al., 2011;Skipworth et al., 2013;Tor et al., 2020)”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G. Owen et al., 2009
Regular programmed activities and medication in hospital improve patients' ability to make treatment decisions over time, even if the intervention lasts only one month.
“On the other hand, it is important to point out that regular programmed activities and medication in hospital seems to improve patients' ability to make treatment decisions over time (Dornan et al., 2015), even if the intervention lasts only one month (G.Owen et al., 2009).”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G.Owen et al., 2009
The Methods (Participants; page not supplied) describe a cross-sectional study with interviews conducted close to admission, not a one-month intervention or follow-up. I searched for a one-month duration and improvement in decision-making capacity over time; the passages found do not address either point. The Owen citation is attached specifically to the one-month qualification. (LLM, conf=0.76)
Experimental — accuracy not yet measured
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- Authors
- Owen, G. S., David, A. S., Richardson, G., Szmukler, G., Hayward, P., & Hotopf, M.
- Affiliations
- King's College London (GB)
- Corresponding author
- Owen, G. S.
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2008-10-22
- Volume
- 39
- Issue
- 8
- Pages
- 1389-1398
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- PMC
- PMC7611628
- OpenAlex
- W2140241730
- Cited by
- 99
- References
- 30
- Citations by year
- 2026: 6 · 2025: 13 · 2024: 7 · 2023: 4 · 2022: 2 · 2021: 3 · 2020: 7 · 2019: 10 · 2018: 4 · 2017: 9 · 2016: 4 · 2015: 4 · 2014: 3 · 2013: 6 · 2012: 5
- FWCI
- 4.46
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Psychological Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- Swinburne figshare (Swinburne University of Technology) (submittedVersion)
- Funders
- Wellcome Trust
- National Institute for Health and Care Research (MAUBRC-2012-1, NF-SI-0507-10088)
- King's College London
- Topics
- Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
- Social Sciences › Psychology › Clinical Psychology › Psychopathy, Forensic Psychiatry, Sexual Offending
- Health Sciences › Health Professions › General Health Professions › Health, Medicine and Society
- Keywords
- decision-making capacity, insight, psychiatric inpatients, psychosis, bipolar disorder, manic episodes, depressive mood, cognitive performance, decision-making, mental health law, capacity assessment
- MeSH terms
- Adult, Alcoholism, Awareness, Mental Disorders, Bipolar Disorder, Cross-Sectional Studies, Decision Making, Depressive Disorder, Expert Testimony, Female, United Kingdom, Humans, Male, Middle Aged, Personality Disorders, Psychotic Disorders, Stress Disorders, Post-Traumatic, Comorbidity, Mental Competency, Substance-Related Disorders
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