From: Depression and decision-making capacity for treatment or research: a systematic review
Author & year | Participants | Depression type/symptom severity | Decision | Measures used | Study objectives | Significant findings |
---|---|---|---|---|---|---|
Appelbaum et al. (1999)[17] | 26 female outpatients pre-selected on basis that they were able to communicate. | DSM–IV major depression. | Research participation | MacCAT-CR scores on understanding, reasoning and appreciating abilities. | Assessment of decision-making abilities to consent to research. | Most subjects performed well on ability measures, maintaining this over the course of their admission. Low scores in appreciation and reasoning measures were recorded in a small subgroup. |
HDRS | Mean scores for: understanding 23.33 (out of max 26); appreciation 4.89 (out of max 6); reasoning 6.5 (out of max 8). | |||||
Mean Score = 18 | ||||||
Range = 15-25 | ||||||
Cohen et al. (2004)[18] | 20 psychiatric inpatients | DSM-IV major depression. | Research participation | MacCAT-CR scores on understanding, reasoning and appreciating abilities. | Assessment of decision-making abilities to consent to 2 research protocols with different risks. | Subjectstended to score in the highest range of all three abilities for both research protocols. The poorest scores were in reasoning but with 90% scoring above the mid point of the reasoning scale in the high-risk study. |
BDI | ||||||
Mean score = 41 | ||||||
SD = 9.5 | ||||||
96 psychiatric inpatients referred for ECT | ‘Major depression unresponsive to medication’ (Personal correspondence from author). Depression type and symptom severity not given in paper. | Treatment participation | Competency Schedule (CIS) scores (a 15 item questionnaire which the authors try to map to 4 standards: evidencing a choice, understanding the issues related to treatment, evidence for a rational reason for the choice, appreciation of the nature of the situation). | To compare physicians’ judgements of competency with scores on the CIS. | Complex presentation of findings. Physician judgments of competency in depressed patients awaiting potential ECT matched well with CIS scores. The item on the CIS that assesses a patients’ ability to specify (or know) the potential benefits of treatment is the best single discriminator of physician judgement (Wilk’s Lambda = 0.49). The authors map this ability to “understanding the issues related to treatment” though, in MacCAT terms, it would map to appreciation: acknowledgement of potential benefit of treatment. | |
Unstructured physician judgments of competency. | 21 patients (21.9%) were categorized by the physician as unable to give consent for ECT. | |||||
Grisso & Appelbaum (1995)[21] | 92 psychiatric inpatients | DSM-IV Major depression. (Severity not reported) | Treatment participation | Pre-cursor instruments to MacCAT-T. Scores on understanding, appreciation and reasoning abilities. | Assessment of decision-making abilities to consent to treatment. | Most subjects scored well on all abilities. Appreciation was most impaired ability. Subjects with scores indicating impairment in: understanding n = 5, (5.4%); appreciation n = 11 (12.0%); reasoning n = 7 (7.6%). |
Compound measures: understanding and/or appreciation n = 17 (18.5%); understanding and/or reasoning n = 11 (12.0%); appreciation and/or reasoning n = 17 (18.5%); understanding, appreciation and/or reasoning n = 22 (23.9%). | ||||||
Lapid et al. (2003)[22] | 40 psychiatric inpatients referred for ECT | DSM-IV major depression including unipolar, bipolar and schizoaffective depression. | Treatment participation | MacCAT-T scores on understanding, appreciation, reasoning and expressing a choice. | Assessment of decision-making abilities to consent to treatment before and after standard and experimental educational intervention. | Subjects scored well both before and after both standard and experimental interventions and both educational interventions increased scores somewhat. |
HDRS | A subgroup of patients with psychotic symptoms (n = 11) scored lower on the appreciation subscale compared with the nonpsychotic group (p < 0.001). The lowest appreciation score was 2 (scale range 0-4) indicating that no subject scored less than the mid-point of the scale. | |||||
Mean =30.35 and 31.30. Range 21.0- 47.0 and 14.0 -42.0. (These apply to the standard and experimental intervention groups respectively). | ||||||
Owen et al. (2008)[2] | 67 psychiatric inpatients | ICD-10 depression (Severity not reported) | Treatment participation | Structured clinical judgment using the MacCAT-T. | Determine prevalence of DMC for treatment in psychiatric inpatients with depression. | 31% lacked DMC for treatment (medication or hospital care) - 95% CI 20-44. |
Owen et al. (2009)[23] | 64 psychiatric inpatients | ICD-10 non-psychotic disorders Depression =46 Post Traumatic Stress Disorder = 3 Personality disorder = 15 (Severity not reported). | Treatment participation | Structured clinical judgment using the MacCAT-T. | To investigate clinical associations with DMC in depressed patients. | Insight in non-psychotic disorders like depression (as opposed to psychotic disorders like schizophrenia, mania) was a poor “test” of DMC. |
Insight measured using the SAI-E | ROC analysis gave an AUC of 0.86. Sensitivity 1.00, specificity 0.44. | |||||
Depressed mood using the BPRS | Severity of depressed mood associated with DMC with large effect size (Hedges’ g 1.25; 95% CI 0.64--‒1.85). | |||||
Owen et al. (2011)[24] | Mixed group of psychiatric inpatients | ICD-10 Schizophrenia and related disorders = 40 Depression = 16 (Severity not reported). | Treatment participation | Structured clinical judgment using the MacCAT-T. | To investigate the association between depression and regaining DMC following 1 month of inpatient psychiatric treatment. | Compared with schizophrenia and related disorders depression was associated with a higher chance of regaining DMC for treatment (OR 5.35, 95% CI 1.47–9.55). |
Vollman et al. (2003)[25] | 35 psychiatric inpatients | ICD-10 Moderate/Severe Depression HDRS: Mean = 21.8. | Treatment participation | MacCAT-T scores on understanding, appreciation and reasoning. | To investigate the competence of patients with depression to make treatment decisions. | Most subjects scored well on all abilities. Appreciation was most impaired ability. Subjects with scores indicating impairment in: understanding n = 5, (5.4%); appreciation n = 11 (12.0%); reasoning n = 7 (7.6%). |
Unstructured physician Judgment | Compound measures: understanding and/or appreciation n = 17 (18.5%); understanding and/or reasoning n = 11 (12.0%); appreciation and/or reasoning n = 17 (18.5%); understanding, appreciation and/or reasoning n = 22 (23.9%). | |||||
One patient with depression (2.9%) was categorized by the physician as unable to give consent for drug therapy. |