Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study
Open accessAbstract
OBJECTIVE: To estimate the prevalence of mental capacity to make decisions on treatment in people from different diagnostic and legal groups admitted to psychiatric hospital. DESIGN: Cross sectional study. SETTING: General adult acute psychiatric inpatient units. PARTICIPANTS: 350 consecutive people admitted to psychiatric wards from the community over 16 months. MAIN OUTCOME MEASURE: Mental capacity assessed by clinical interview and the MacArthur competence assessment tool for treatment. RESULTS: Estimates of mental capacity were obtained on 97% (n=338) of the 350 people admitted. Of those an estimated 60% (95% confidence interval 55% to 65%) lacked mental capacity to make decisions on treatment. This proportion varied according to diagnosis, ranging from 97% (n=36) in people with mania to 4% (n=24) in people with personality disorder. Mental incapacity was common in patients admitted informally to the psychiatric wards (n=188; 39%, 32% to 46%). Incapacity and detention are closely associated under non-capacity based mental health law. CONCLUSIONS: Mental incapacity to make decisions on treatment is common in people admitted to psychiatric wards from the community but cannot be presumed. It is usual in those detained under the Mental Health Act and common in those admitted voluntarily.
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When mental illness impairs capacity, it most frequently affects the 'appreciation' dimension, which reflects a person's ability to apply the consequences of a decision to themselves.
“When mental illness impairs capacity, it most frequently affects the “appreciation” dimension, which reflects a person’s ability to apply the consequences of a decision to themselves (53).”
From Assisted death in eating disorders: a systematic review of cases and clinical rationales (2024) · cites this paper as [53]
The 'Assessments by clinical researcher' section lists appreciation as one of four abilities assessed for treatment decisions. It does not define appreciation as applying consequences to oneself or report that it is the dimension most frequently affected; the Results report overall incapacity, not frequencies by ability. Page numbers are unavailable in our copy. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe remaining studies show high heterogeneity in the decision to be evaluated and in the rate of incapacity, which ranges from 10% to 87% in the samples.
“The remaining studies show high heterogeneity in the decision to be evaluated, without specifying the treatment (Kahn et al., 2009;Okai et al., 2007;G. S. Owen et al., 2008G. S. Owen et al., , 2011) ) as well as in the rate of incapacity, which ranges from 10% to 87% in the samples.”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G. S. Owen et al., 2008
The Assessment of mental capacity section distinguishes decisions about taking prescribed drugs from decisions about hospital admission, supporting variation in the decision assessed; it does not leave the decision unspecified. The Results report 60% incapacity overall, while Table 2 reports subgroup rates from 4% to 97%. This paper therefore does not establish the claimed 10%–87% range across the cited studies. (LLM, conf=0.85)
Experimental — accuracy not yet measuredIn only one paper, there were higher rates of incapacity for manic BPAD patients (97%) compared to schizophrenia (81%), although this difference was non-significant.
“In only one paper, there were higher rates of incapacity for manic BPAD patients (97%; 95% CI [86 -100%]) compared to schizophrenia (81%; 95% CI [71 -89%]) (G. S. Owen et al., 2008) although this difference was non-significant.”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G. S. Owen et al., 2008
Table 2 (p. 2) reports incapacity in 97% of patients with bipolar affective disorder–mania (95% CI 86–100%) and 81% of patients with schizophrenia (95% CI 71–89%). The Statistical analysis section describes estimating prevalence and confidence intervals, but the paper does not report a significance test for the difference between these groups; the claim that it was non-significant is therefore unsupported. (LLM, conf=0.88)
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. S. Owen et al., 2008
Table 2 (p. 2) estimates that 31% of admitted patients with depression lacked capacity to make treatment decisions, so incapacity did occur in this group. The Discussion (p. 3) says incapacity rates were lower for depression than for mania and schizophrenia; the paper does not establish that depression was associated with an increased risk of incapacity. (LLM, conf=0.84)
Experimental — accuracy not yet measuredBlack African and Black Caribbean patients were significantly less likely to have capacity to make treatment decisions.
“More specifically, Black African (OR = 0.14, 95% CI [0.05 -0.37]) and Black Caribbean (OR = 0.32, 95% CI [0.13 -0.78]) patients were significantly less likely to have capacity to make treatment decisions.”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G. S. Owen et al., 2008
The Results and Table 2 (p. 2) report treatment-decision capacity by diagnosis and legal status, not by ethnicity. Searches for Black African and Black Caribbean patients and for the stated odds ratios found no corresponding comparison in our copy; Table 1’s data are not available in the indexed text. (LLM, conf=0.74)
Experimental — accuracy not yet measured
In 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. S. Owen et al., 2008
The Discussion reports lower rates of incapacity among patients with depression, and Table 2 gives a prevalence of 31%, but neither addresses whether poor insight predicts incapacity. A search for “insight” found no passage assessing that relationship. The separate claim about regaining capacity is attributed to Owen et al. (2009), not this source. (LLM, conf=0.76)
Experimental — accuracy not yet measuredTwo studies found that Black ethnicity was associated with poorer capacity, compared to White European ethnicity.
“Regarding ethnicity, two studies found that Black ethnicity was associated with poorer capacity, compared to White European ethnicity (G. S. Owen et al., 2008Owen et al., , 2011)).”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G. S. Owen et al., 2008
The Results and Table 2 report incapacity by diagnosis and legal status, not by ethnicity. Searches for Black ethnicity and White European ethnicity found no passage in our copy comparing their capacity, so this paper’s contribution to the cited claim cannot be verified. (LLM, conf=0.72)
Experimental — accuracy not yet measuredBlack patients were significantly less likely to regain capacity for treatment decisions, compared to White patients (OR = 0.29, 95% CI [0.11 -0.74]).
“Black patients were significantly less likely to regain capacity for treatment decisions, compared to White patients (OR = 0.29, 95% CI [0.11 -0.74]).”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as G. S. Owen et al., 2008
The Results (p. 2) report capacity assessed shortly after admission and prevalence by diagnosis and legal status, not whether patients later regained capacity. Searches for Black–White comparisons and the stated odds ratio found no passage addressing either; the cross-sectional findings cannot verify the claim. (LLM, conf=0.76)
Experimental — accuracy not yet measuredAnother study using the McCAT-T indicated that only 4% of patients with a personality disorder lacked decisional capacity, whereas 80% of patients with acute psychosis due to schizophrenia lacked capacity.
“By diagnosis, capacity can vary; another study using the McCAT-T indicated that only 4% of patients with a personality disorder lacked decisional capacity, whereas 80% of patients with acute psychosis due to schizophrenia lacked capacity.”
Among those with severe unipolar depression, in this same study, only 31% lacked capacity.
“Among those with severe unipolar depression, in this same study, only 31% lacked capacity.”
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- Authors
- Owen, G. S., Richardson, G., David, A. S., Szmukler, G., Hayward, P., & Hotopf, M.
- Affiliations
- King's College London (GB)
- Maudsley Hospital (GB)
- Corresponding author
- Hotopf, M.
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2008-06-30
- Volume
- 337
- Issue
- jun30 1
- Pages
- a448-a448
- ISSN
- 0007-1447 (ISSN-L)
- 0959-8138
- 1468-5833
- PMC
- PMC2443596
- OpenAlex
- W2028742543
- Cited by
- 172
- References
- 7
- Citations by year
- 2026: 4 · 2025: 8 · 2024: 9 · 2023: 8 · 2022: 3 · 2021: 8 · 2020: 8 · 2019: 10 · 2018: 5 · 2017: 11 · 2016: 9 · 2015: 9 · 2014: 9 · 2013: 15 · 2012: 7
- FWCI
- 18.17
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- BMJ (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Swinburne figshare (Swinburne University of Technology) (submittedVersion)
- Funders
- Wellcome Trust
- Topics
- Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
- Health Sciences › Health Professions › General Health Professions › Health, Medicine and Society
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Ethics and Legal Issues in Pediatric Healthcare
- Keywords
- decision-making capacity, psychiatric inpatients, treatment decision-making, Mental Health Act detention, voluntary admission, mania, personality disorders, mental health law
- MeSH terms
- Adult, Mental Disorders, Cross-Sectional Studies, Decision Making, England, Female, Hospitalization, Hospitals, Psychiatric, Humans, Informed Consent, Male, Mental Health Services, Wales, Mental Competency
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