Decision-making Capacity for Treatment After Electroconvulsive Therapy for Depression.

OBJECTIVES: Depression can impair decision-making capacity (DMC) for health care decisions. However, it is unclear whether DMC improves after treatments for depression such as electroconvulsive therapy (ECT). There is limited evidence available on DMC for treatment in patients with depression referred for ECT, and it is unknown whether ECT has any impact on DMC. We hypothesized that ECT will improve DMC in severely depressed patients and that this change will be associated with reduced depressive symptom severity. METHODS: Using the MacArthur Competence Assessment Tool-Treatment, 4 abilities related to DMC were evaluated: Understanding, Appreciation, Reasoning, and Expressing a choice. This prospective study compared DMC abilities, depression severity, and cognition scores in 24 patients hospitalized with a major depressive episode before and 3 to 5 days after a course of ECT. RESULTS: Although Understanding scores significantly improved after ECT (P = 0.004, r = 0.41), there was no change in other abilities related to DMC or cognition scores. As expected, there was a large improvement in mood ratings after ECT, but the change in DMC abilities was not associated with change in depressive symptoms. CONCLUSIONS: To our knowledge, this is the first study to provide data on the effects of ECT on DMC in patients with depression. Abilities related to DMC that may be affected in this group before treatment include Understanding and Reasoning. Findings indicate that DMC to consent to treatment mostly does not change after a course of ECT and some aspects can improve in patients with depression.

Drawing on emotions: the evolving role of art therapy.

Art therapy is a form of psychotherapy that uses art media to improve well-being. This article explores the history and development of art therapy, from the first description of art therapy in the 1940s, to the two main approaches still in use today. The benefits of art therapy with regard to its delivery, patient population, and cost are then broadly discussed. The use of art therapy in psychiatric conditions, specifically in schizophrenia and schizophrenia-like conditions, is highlighted, as well as its role in chronic and physical conditions like asthma and cancer. Furthermore, the potential for art therapy to be more broadly implemented using technological novelties, such as virtual reality, is considered, especially in light of the COVID-19 pandemic.

Antitumour and antimalarial activity of artemisinin-acridine hybrids.

Artemisinin-acridine hybrids were prepared and evaluated for their in vitro activity against tumour cell lines and a chloroquine sensitive strain of Plasmodium falciparum. They showed a 2-4-fold increase in activity against HL60, MDA-MB-231 and MCF-7 cells in comparison with dihydroartemisinin (DHA) and moderate antimalarial activity. Strong evidence that the compounds induce apoptosis in HL60 cells was obtained by flow cytometry, which indicated accumulation of cells in the G1 phase of the cell cycle.

Functional mental capacity is not independent of the severity of psychosis.

BACKGROUND: Function-specific mental capacities are the legal criteria for competence. These are regarded as superior to clinical assessments of mental state and general function. AIMS: To determine whether tests of fitness to plead and capacity to consent are independent of each other and independent of mental state and global function in psychosis. METHOD: The MacCAT-T and MacCAT-FP, PANSS and GAF were administered to 102 compulsorily detained forensic patients with psychosis. Criteria for incompetence were inability to express a preference concerning treatment, and independent rating as unfit to plead. RESULTS: MacCAT-T, MacCAT-FP totals and sub-scales correlated with each other and with PANSS and GAF. Those independently rated unfit to plead or who were incapable of making a treatment choice scored significantly worse on all rating scales. No test had satisfactory sensitivity or specificity. CONCLUSIONS: Legal definitions of mind and of functional capacity offer a basis for structured clinical judgement regarding decision-making capacity. However, function-specific measures of understanding, reasoning and appreciation generate much the same results as measures of mental state and global functioning.

The recovery of factors associated with decision-making capacity in individuals with psychosis.

BACKGROUND: There is limited data on the recovery of factors associated with decisional capacity in patients with psychosis. AIMS: To study the relationship between changes in mental capacity, symptoms and global functioning using structured measures during treatment for psychosis. METHOD: Fifty-six patients with psychosis were assessed for capacity to consent to treatment on admission and at 6 and 12 weeks following treatment. The MacArthur Competence Assessment Tool - Treatment, the Positive and Negative Symptom Scale and the Global Assessment of Functioning Scale were used to measure mental capacities, symptom severity and global functioning respectively. Treating consultants rated capacity to consent, masked to these measures. RESULTS: Greater impairments on all measures were found in patients assessed as lacking capacity. These improved with treatment over 12 weeks with significant effect sizes (0.5 to 0.6). Stronger correlations between mental capacities, positive symptoms (-0.47) and global functioning (0.56) were noted in the first 6 weeks. CONCLUSIONS: Impairments in capacity in acute stages of psychosis are related to symptom severity and functional impairment. They improve during treatment, particularly in the first 6 weeks. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Functional mental capacity, treatment as usual and time: magnitude of change in secure hospital patients with major mental illness.

BACKGROUND: Decision making ability can change with time, depending on mental or physical health. Little is known about the factors that determine this change and the relationship of capacity to time. As a pilot for studies using functional mental capacities as an outcome measure, we sought to quantify this relationship measuring change over time using competence assessment tools, and rating scales for symptoms and global function. METHODOLOGY: We assessed 37 inpatients in a secure psychiatric hospital. All patients met the diagnostic and statistical manual of mental disorders-fourth edition and International classification of diseases, 10th edition criteria for an Axis 1 mental illness, all with psychosis. Patients were interviewed twice a mean of 323 days apart (median 176 days range 17-1221 days). The MacArthur competence assessment tools for consent to treatment (MacCAT-T) and fitness to plead (MacCAT-FP) were used to quantify functional capacity along with the Positive and Negative Syndrome Scale (PANSS) and global assessment of function (GAF) scale. A comparison was also made between those patients prescribed clozapine in comparison to other antipsychotics. RESULTS: The number judged by treating psychiatrists to lack capacity either to make a treatment choice or to plead in court fell from 35 to 8%. Change was greatest for those admitted within the previous 9 months. The measures of capacity improved between time 1 and time 2 for both consent to treatment and fitness to plead. The measures of capacity improved with positive symptoms within the PANSS and with GAF scores. Those with shorter lengths of stay at baseline had the greatest improvements in the MacCAT-FP scores. Effect sizes were medium or large (0.3-0.7+). As expected, patients prescribed clozapine had larger changes in functional mental capacities and larger effect sizes than those prescribed other psychotropics. The results show a strong relationship between the clinicians' assessment of capacity and structured rating scales. CONCLUSIONS: We have shown that there is an improvement in capacity scores with time. More research is needed to compare the effect of treatment on capacity at fixed time intervals. It would also be helpful to look at a more general patient population.

Extra information about treatment is too much for the patient with psychosis.

BACKGROUND: Case law across jurisdictions requires ever more complete disclosure of material facts when obtaining consent to treatment. AIMS: To determine whether giving extra information impairs the mental capacity to make decisions about treatment. METHOD: The MacCAT-T, MacCAT-FP, PANSS and GAF were administered to 88 detained forensic patients with psychosis. Two positive and two negative facts were given about each of two anti-psychotic drugs, and no treatment (twelve items). A choice was elicited. The criterion for incompetence was inability to express a choice. Two extra positive and two extra negative facts about each of the three options were given (twelve extra items) and a choice was again elicited, while repeating the MacCAT-T. RESULTS: Giving extra information led to a decline in the total score on the MacCAT-T. Twenty one were initially unable to make a choice (24%). After additional information, 33 were incapable (37.5%, Chi-squared p<0.001). Those initially incapable had the lowest scores on all measures of functional capacity and GAF, with highest scores for symptoms. Those able to choose a treatment option had the highest levels of function and least symptoms. Those who became incapable had intermediate scores. CONCLUSIONS: Giving extra information made an extra 15% unable to choose. Clinical judgement must be exercised concerning the amount of information disclosed. Deciding what is material to the individual is arbitrary when so few items of information can be processed. Greater use of guardianship and independent second opinions is recommended.

A review of recorded information given to patients starting to take clozapine and the development of guidelines on disclosure, a key component of informed consent.

Clozapine is a very effective drug with both significant benefits and significant risks in treatment-resistant schizophrenia. Informed consent is generally accepted as both desirable and necessary in order to ensure that the patient's human rights and dignity are respected. Disclosure is a key element of informed consent. It is unclear if the adequate documentation of disclosure is standard practice before initiation of clozapine. The aim of this study was to assess the adequacy of the documentation of disclosure in consent to clozapine treatment in an adult mental health service and to develop guidelines on disclosure. The method was a retrospective analysis of charts of patients given clozapine who received the drug through the pharmacy of a single North Dublin psychiatric hospital. Results show that current practice has evident gaps. The professional, ethical and legal issues are discussed.