Establishing competency in mentally ill

1. Dr Akhila K Chandran
Research Ethics Scholar
Centre for Ethics
Yenepoya Deemed to be University
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2. ROAD MAP
 Mental health, mental disorder
 Mental illness(MCA)
 Impacts of mental disorders
 Competence
 Competency vs capacity
 Fluctuating capacity
 Lack of capacity
 Components of capacity evaluation
 Standards for assessing decision making capacity
 2 stage functional test for capacity
 Competency assessment- who?, when?, why?, how?
 Competency assessment tools- MacCAT-T, MacCAT-CR
 Limitation of competency assessment tools
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3. MENTAL
HEALTH
A state of well-being in which an
individual realizes his or her own
abilities, can cope with the
normal stresses of life, can work
productively and fruitfully, and
is able to make a contribution to
his or her community
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4. MENTAL
DISORDERS
As per WHO-
“Mental disorders comprise a broad range of problems, with
different symptoms. However, they are generally characterized
by some combination of abnormal thoughts, emotions,
behavior and relationships with others.”
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5. Mental illness
A substantial disorder
of
 thinking
 mood
 perception
 orientation or
 memory
It does not include mental retardation
that grossly impairs
 judgment,
 behavior,
 capacity to recognize reality or
 ability to meet the ordinary demands
of life,
 mental conditions associated with the
abuse of alcohol and drugs.
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6. Individual-
poor quality of life, stigma
and discrimination, stress
restriction of social activities
,suffering from physical
illnesses ,are unable to
participate in work and
leisure
Family-
stigma and
discrimination, stress
,economic loss,
restriction of social
activities
Society-
Economic loss, violence,
crimes
Impact of
mental
disorders

7. Competence
As per MerriamWebster- “the quality or state of having
sufficient knowledge, judgment, skill, or strength (as for
a particular duty or in a particular respect)”
In law- legal authority, ability, or admissibility.
In mental health-
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8. Competency vs.
Capacity
Capacity- A person’s ability to make an informed decision;
a physician can determine capacity.
Competency-The degree of
mental soundness necessary to
1. make decision about specific issues or
2. carry out a specific act;
Competency- A judicial finding made by the court, not by
a physician.
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9. FLUCTUATING
CAPACITY
Fluctuating capacity means that a P at some
times has the mental capacity pursuant to the
MCA to make decisions and sometimes does
not.
The main MCA 2005 Code of Practice notes
that some people have fluctuating capacity
as a result of “a problem or condition that
gets worse occasionally and affects their
ability to make decisions” (the examples
being given are manic depression (or, as it is
now termed, bipolar disorder) or a
psychotic illness).
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10. 3 broad groups:
Those with mental
illness who have a
temporary episode of
crisis or those who
experience a change in
their physical health
which impacts on their
mental functioning
Those whose capacity
fluctuates on a
predictable basis and in
circumstances which
are easily identifiable.
Those whose
fluctuations in their
capacity are
unpredictable.
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11. Temporary
factors that
may also affect
someone’s
ability to
make
decisions-
Distress
after a
death or
shock.
The effect
of
medication,
or
Severe
pain,
Acute
illness,
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12. The
consequences
of fluctuating
capacity will
depend upon
the context.
a)There may be situations in which a person’s
fluctuating capacity will solely impact upon the
extent to which they can be held to the legal
consequences of their actions (for instance in
relation to property and affairs);
b) there may also be situations in which their
fluctuating capacity will impact upon the ability of
others to rely upon their consent (most obviously in
relation to capacity to consent to sexual relations
but also when consenting to medical treatment).
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13. Lack of capacity
a) to understand the information relevant to the
decision,
b) to retain that information,
c) to use or weigh that information as part of
the process of making the decision, or
d) to communicate his decision (whether by
talking, using sign language or any other
means) (2)
“A person lacks capacity in
relation to a matter if at the
material time he is unable
to make a decision for
himself in relation to the
matter because of an
impairment of, or a
disturbance in the
functioning of, the mind or
brain.”(1)
A person is unable to make a decision for himself if he is
unable
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14. A lack of
mental
capacity could
be due to:
a stroke or brain injury
a mental health problem
dementia
a learning disability
confusion, drowsiness or unconsciousness because of an illness of the
treatment for it
substance misuse
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15. Components of a
capacity evaluation
 Comprehension
It refers to a patient’s factual understanding of his /her medical
condition—for example, including the risks and benefits of treatment
and reasonable alternatives. The patient should show an understanding
of 1) the situation as it relates to his condition, and 2) the consequences
of his decisions. He also should demonstrate a rational manipulation of
the information presented, applying a coherent and logical thought
process to analyze possible courses of action.
 Free choice
The patient’s decision to accept or reject a proposed treatment should
be voluntary and free of coercion. In assessing a patient’s capacity, the
psychiatrist should determine whether choices have been rendered
impossible because of unrealistic fears or expectations about
treatment, or because of impaired mental processes.
 Reliability
it refers to a patient’s ability to provide a consistent choice over time. A
patient who vacillates or is inconsistent does not have capacity to make
decisions.
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16. Standards for
assessing
decision-
making
capacity
Ability to Evidence a Choice.
Ability to Understand Relevant Information.
Ability to Appreciate the Situation and Its
Likely Consequences.
Ability to Manipulate Information Rationally.
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17. 1.Ability to Evidence aChoice.
 least stringent component
 Individuals failing this criterion -unable to express a preference or are unable to
make their wishes known effectively.
 Here we look at whether or not a decision was made.
 It requires the ability to maintain and communicate stable choices long enough for
them to be implemented.
 For e.g., an individual who rapidly changes his or her decision from moment to
moment -deemed unable to evidence a choice.
.
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18.  Furthermore, individuals with impairment of consciousness, with
significant thought disorders, deficits in short-term memory or
lability that impairs decision making are likely to have difficulties
with the ability to evidence a choice.
 This can be tested quite simply by asking patients who have been
informed about their medical condition and proposed
interventions to respond to what they have just heard.
 The stability of the choice that they express can be examined by
simply rephrasing the same question some time later
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19. 2.Ability toUnderstand Relevant Information.
 This component is adhered to by every jurisdiction.
 It goes beyond evidencing a choice by assessing the individual's ability to
comprehend information disclosed in the informed consent process.
 Basis-an individual who cannot understand what he or she has been told about a
proposed treatment or diagnostic intervention is not capable to decide to assent
or refuse.
 The ability to understand relevant information can be best assessed by asking
patients to disclose their understanding of the proposed treatment intervention or
diagnostic procedure. It is best to ask them to paraphrase it.
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20. 3.Ability toAppreciate theSituation and Its Likely
Consequences
 This standard assesses whether the patient comprehends what the proposed
intervention means for him or her.
 Here the information that is being assessed is whether the individual understands
what having the illness means, including its course and likely outcomes. In
addition, the probable consequences of treatment or its refusal and the likelihood
of each of a number of consequences, such as undergoing treatment versus
forgoing treatment versus alternative treatments, are assessed.
 The concept of appreciation is a rather individualized component of the capacity
assessment.
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21. 4.Ability to Manipulate Information Rationally.
 This component refers to the patient's general ability to employ logic or rational
thought processes to manipulate information.
 Basis- If patients are unable to use logic and unable to weigh information in a
rational manner to reach a decision, they will therefore be unable to compare the
benefits and risks of various treatment options or interventions proposed to them.
 This component does not focus on the ultimate decision that the patient makes,
but rather the process.
 Therefore, the physician examines the ability of individuals to reach a conclusion
based on the initial premises with which they start.
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22. Two-stage
functional test
of capacity
Stage 1. Is there an impairment of
or disturbance in the functioning of
a person’s mind or brain? If so,
Stage 2. Is the impairment or
disturbance sufficient that the
person lacks the capacity to
make a particular decision?
In order to decide whether an individual has the capacity to make a
particular decision you must answer two questions:
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23. understand information given to them
Understand
retain that information long enough to be able to make the decision
Retain
weigh up the information available to make the decision
Weigh up
communicate their decision – this could be by talking, using sign language or
even simple muscle movements such as blinking an eye or squeezing a hand.
Communicate
The MCA says that a person is unable to make their own decision if they
cannot do one or more of the following four things:
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24. Competency
Assessment
Who ?
When?
Why?
How?
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25. Who?
Courts determine competence by a formal judicial proceeding.(1)
A psychologist/neuropsychologist can have two roles in this regard:
(a) he/she may be the clinical care provider and assessing the patient's
capacity for the clinical procedures he/she is initiating in that role
or
(b) (b) he/she may be acting as a consultant for another clinician, that
is, asked to provide an expert opinion regarding the decisional
capacity of the patient of another healthcare provider.(2)
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26. When?
In Healthcare-
 When a patient is admitted for any treatment or emergency
procedures.
In Research-
 When a participant with known h/o of any mental illness is
included in the research
 When a mentally ill patient is included in the research.
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27. Why?
Assessment of mental capacity may relate to any act
including criminal law (competency to stand trial, consent,
private defense against an insane person) to civil law
(contract, marriage, adoption, laws to prevent/ treat mental
illnesses-health and welfare decisions), choices about the
most appropriate place to live, e.g., full time residential or
nursing care and also illnesses and legal transactions.
Systematic assessment of mental capacity of individuals
undergoing studies or taking treatment will help in diffusing
the ethical controversies.
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28. How?
 By using standardized tools for the assessment of
competency.
They are
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29. Competency
Assessment
Tools
The Mini Mental Status Examination (MMSE)
Hopkins Competency AssessmentTest (HCAT)
Capacity to Consent toTreatment Instrument (CCTI)
MacArthur CompetenceAssessmentTool –Treatment (MacCAT-T)
MacArthur CompetenceAssessmentTool – Clinical Research (MacCAT-
CR)
MaxArthur CompetenceAssessmentTool- CriminalAdjudication
(MacCaT-CA)
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30. Competency Interview Schedule (CIS)
Structured Interview for Competency/IncompetencyAssessment
Testing and Ranking Inventory (SICIATRI)
Evaluation to Sign Consent (ESC)
Aid to Capacity Evaluation (ACE)
California Scale of Appreciation (CSA)
CapacityAssessmentTool (CAT)
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31. MacArthur
Competence
Assessment
Tool –
Treatment
(MacCAT-T)
• Assesses choice,
understanding,
appreciation, and
rational thinking
• Adequate,
partial, or
inadequate ratings
for each item
• Score for each
ability
• Not designed
to determine
global
competence
• Intended to
identify areas of
relative capacity
• Semi-structured
interview
• 15-20 min
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32. Pros
• High inter-rater reliability
• Correlates with MMSE
• Utilizes patient chart to make test personally
relevant
• Moderate agreement with physician ratings
• Practical for cases of ambiguous competency
Cons
• May not be valid in every population: anorexia
nervosa
• Procedure for going over the facts of disorder
and treatment “Patronizing” and “Awkward”
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33. MacArthur
Competence
Assessment
Tool –Clinical
Research
(MacCAT-CR)
• Assesses
choice,
understanding,
appreciation, and
rational thinking
• Structured interview
• 15-20 min
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34. Pros
• Can be customized to research protocol and
diagnostic sample
• High inter-rater reliability
• Correlates with MMSE
Cons
• Possibly low test retest reliability – ceiling
effects
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35. Limitations to
Competency
Assessment
Tools
• Legal definition varies by jurisdiction
• Every patient / clinical decision is unique
• Informed consent is required for participation in research so those
who are incompetent to consent cannot be studied
• Only authorized persons or groups (judge) can declare
incompetent – gold standard?
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36. Thank you..
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