Depressed, Suicidal, and Likely Less Able to Consent to Treatment

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Among individuals with depression, those who have attempted suicide were found to have less capacity to provide informed consent for treatment, according to the results of a study¹ relating history of suicide attempts with impaired decision-making.

“The suicide attempt history has never been considered in studies on the capacity to consent to treatment, although it is associated with depression severity and cognitive impairment that may affect decision-making capacity,” indicated Emilie Olié PhD, MD, of the Department of Emergency Psychiatry and Acute Care at Lapeyronie Hospital, Centre Hospitalier Universitaire (CHU) Montpellier, Montpellier, France, and colleagues.

“Indeed, suicide attempters display impaired decision-making abilities; lower problem-solving, leading to feelings of entrapment; and lack of future positive thinking,” Olié and colleagues noted, citing several previous studies.

To isolate the relation of suicide attempts to decision-making in individuals with depression, the investigators administered the MacArthur Competence Assessment Tool for Treatment (MacCAT-T)² to 60 adult patients in a current depressive episode, with (n=33) and without (n=27) history of attempted suicide. The median Beck Depression Inventory (BDI) score of depression severity was 21 (10 to 36).

The MacCAT-T measures 4 dimensions relevant to the patient's capacity to make decisions from information disclosures about their illness to the nature of treatment options and their risks and benefits:

1. Understanding the disclosed information
2. Appreciation, or appreciating the significance of the information to one's condition and situation
3. Reasoning about the potential risks and benefits of one's choices
4. Expressing choice, or communicating choices regarding proposed treatment

“If 1 of these 4 areas is impaired, a patient may be considered unable to exercise their autonomy relative to treatment decision-making,” Olié and colleagues explained. “Appreciation, which requires comparing several alternatives, seems to be the most altered decision-making capacity component in individuals with depression.”

In addition to the MacCAT-T and the BDI, the investigators administered the Beck Cognitive Insight Scale (BCIS) and quantified insight using the BCIS composite index (subtracting the self-certainty subscale score from the self-reflection subscale score).

“In general, the capacity to consent is a dimension that is often overlooked because it is challenging to evaluate for clinicians,” Olié told Psychiatric Times®. “Nevertheless, collective reflection on this dimension is crucial in our patient care.”

Across both groups, the median MacCAT-T sub-scores were 4.62 (2.35 to 6) for Understanding, 3 (1 to 4) for Appreciation, 5.5 (1 to 8) for Reasoning, and 2 (0 to 2) for Expressing Choice. The investigators determined that capacity to consent was impaired in 36 patients (60%) with low scores for Understanding, in 18 (30%) scoring low in Appreciation, and in 32 (53%) scoring low in Reasoning. They found no association of insight with decision-making, however, with a median BCIS composite index of 2 (-15 to 22).

In their comparison of those with and without a lifetime history of suicide attempt, those who had attempted suicide had a higher number of past depressive episodes and greater severity of symptoms, but a lower BCIS composite index. Suicide attempt was associated with lower MacCAT-T sub-scores than those with no history of suicide attempt: Understanding was 4.4 (2.35 to 8) versus 5.3 (3 to 13.6), Appreciation was 3 (1 to 4) versus 4 (2 to 4), Reasoning was 4 (1 to 7) versus 7 (3 to 8), and Expressing Choice was 1 (0 to 2) versus 2 (0 to 2).

In addition to supporting the hypothesis that some patients with greater depressive symptomatology have impaired decision-making capacity, the investigators emphasized that their results “add that history of suicide attempt is associated (with) impaired decision-making capacity in depressed patients.”

Impaired Decision-Making and Assist-To-Die

“We have been concerned with the capacity to consent of depressed patients, particularly those at risk of suicide, following a review of data regarding euthanasia in psychiatric patients,” Olié recounted when discussing the study with Psychiatric Times. “These data indicate that the capacity to consent is rarely assessed in these patients, making this issue central.”

Assist-to-die services for the terminally ill, and in some jurisdictions for incapacitation, commonly exclude individuals with mental illness that would impair the capacity to grant informed consent. Olié and colleagues cited a Dutch study,³ however, that found that the capacity to consent is commonly based on a global judgment of the patient's capacity and was determined in only 55% of a national assist-to-die cohort; most of these patients had depression, and many had a history of suicide attempts.

“Importantly, many patients had refused potential effective treatments before requesting and receiving assisted suicide,” observed Olié and colleagues, who suggested that using the MacCAT-T to better assess the capacity to consent might have averted resorting to an assist-to-die service.

“Through our findings, we aim to emphasize the need for clinicians to be vigilant in this regard and to be more proactive in promoting understanding and acceptance of treatment tailored to depressed patients at risk of suicide,” Olié said. “This represents a potential avenue for improving suicide prevention.”

Dr Bender reports on medical innovations and advances in practice and edits presentations for news and professional education publications. He previously taught and mentored pharmacy and medical students, and provided and managed pharmacy care and drug information services.

References

1. Olié E, Catanzaro T, Malestroit M, et al. The capacity to consent to treatment is altered in suicidal patients. Ann Gen Psychiatry. 2023;22(1):35.

2. Grisso T, Appelbaum PS. The MacArthur Treatment Competence Study. III: Abilities of patients to consent to psychiatric and medical treatments. Law Hum Behav. 1995;19(2):149-174.

3. Doernberg SN, Peteet JR, Kim SY. Capacity evaluations of psychiatric patients requesting assisted death in the Netherlands. Psychosomatics. 2016;57(6):556-565.