Abstract
BackgroundPsychiatric disorders can pose problems in the assessment of decision-making capacity (DMC). This is so particularly where psychopathology is seen as the extreme end of a dimension that includes normality. Depression is an example of such a psychiatric disorder. Four abilities (understanding, appreciating, reasoning and ability to express a choice) are commonly assessed when determining DMC in psychiatry and uncertainty exists about the extent to which depression impacts capacity to make treatment or research participation decisions.MethodsA systematic review of the medical ethical and empirical literature concerning depression and DMC was conducted. Medline, EMBASE and PsycInfo databases were searched for studies of depression and consent and DMC. Empirical studies and papers containing ethical analysis were extracted and analysed.Results17 publications were identified. The clinical ethics studies highlighted appreciation of information as the ability that can be impaired in depression, indicating that emotional factors can impact on DMC. The empirical studies reporting decision-making ability scores also highlighted impairment of appreciation but without evidence of strong impact. Measurement problems, however, looked likely. The frequency of clinical judgements of lack of DMC in people with depression varied greatly according to acuity of illness and whether judgements are structured or unstructured.ConclusionsDepression can impair DMC especially if severe. Most evidence indicates appreciation as the ability primarily impaired by depressive illness. Understanding and measuring the appreciation ability in depression remains a problem in need of further research.
Highlights
Psychiatric disorders can pose problems in the assessment of decision-making capacity (DMC)
Inclusion criteria required that selected papers were (1) in the English language; (2) included significant clinical ethical analysis or contained relevant observational data using DMC assessment tools in depressed individuals
The search was augmented through examination of cited material within the selected papers for further relevant material suitable for inclusion
Summary
Psychiatric disorders can pose problems in the assessment of decision-making capacity (DMC). This is so where psychopathology is seen as the extreme end of a dimension that includes normality. Four abilities (understanding, appreciating, reasoning and ability to express a choice) are commonly assessed when determining DMC in psychiatry and uncertainty exists about the extent to which depression impacts capacity to make treatment or research participation decisions. The ability to understand information relevant to treatment decision making 3. The ability to appreciate the significance of that information for one’s own situation, especially concerning one’s illness and the probable consequences of one’s treatment options; and. 4. The ability to reason with the relevant information so as to engage in a logical process of weighing treatment options
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