PAPER PSYCHIATRY AND BEHAVIORAL SCIENCES Gabriele Mandarelli, 1 M.D.; Lorenzo Tarsitani, 2 M.D., Ph.D.; Giovanna Parmigiani, 2 M.D.; Gian M. Polselli, 2 M.D.; Paola Frati, 3 J.D.; Massimo Biondi, 2 M.D.; and Stefano Ferracuti, 1 M.D. Mental Capacity in Patients Involuntarily or Voluntarily Receiving Psychiatric Treatment for an Acute Mental Disorder ABSTRACT: Despite the growing amount of data, much information is needed on patients’ mental capacity to consent to psychiatric treat- ment for acute mental disorders. The present study was undertaken to compare differences in capacity to consent to psychiatric treatment in patients treated voluntarily and involuntarily and to investigate the role of psychiatric symptoms, competency, and cognitive functioning in determining voluntariness of hospital admission. Involuntary patients were interviewed with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the 24-item Brief Psychiatric Rating Scale (BPRS), the Mini Mental State Examination (MMSE) and the Raven’s Colored Progressive Matrices, and their data were compared with those for age- and sex-matched voluntary patients. Involuntary patients per- formed worse in all MacCAT-T subscales. Capacity to consent to treatment varied widely within each group. Overall, involuntary patients have worse consent-related mental capacity than those treated voluntarily, despite capacity to consent to treatment showing a significant variability in both groups. KEYWORDS: forensic science, informed consent, mental competency, affective disorders, schizophrenia, health care ethics Even though treatment-related decisional capacity raises crucial clinical and ethical concerns, the factors underlying poor mental capacity remain unclear, especially in acute psychiatric coercive settings. Nor has research yet explained why and how mental capacity to make decisions about treatment varies widely in patients admitted voluntarily or involuntarily to a psychiatric patient unit for a mental disorder. Despite common perceptions, capacity is frequent in patients with mental disorders, and it has complex relationships with clinical and nonclinical factors (1). In a systematic review, Okai and colleagues (2) reported that unlike most psychiatric in-patients, those receiving involuntary psychi- atric treatment tended to lack mental capacity. The few studies that have specifically evaluated treatment decision-making capac- ity in patients who undergo psychiatric treatment voluntarily or involuntarily have reported discrepant results mainly owing to methodological problems including heterogeneous study samples and assessment methods (3–7). For example, whereas some found no significant differences in treatment capacity between patients admitted voluntarily or involuntarily (3), others found that an involuntarily-admitted subgroup scored worse on a scale measuring information understanding (4). Yet others reported that a small sample of patients detained under the Mental Health Act 1983 lacked mental capacity to decide about hospital admis- sion (5) and treatment (6). In a study assessing a mixed sample of voluntary and detained in-patients with a reliable measure, the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), Cairns and colleagues (7) found that 43.8% of all in-patients lacked capacity, and 9.5% of detained patients had competence to consent to treatment. Among clinical factors asso- ciated with incapacity, the investigators identified the presence of mania, psychosis, delusions, and poor insight (8). In more recent years, Owen and colleagues (9) found that 60% (95% CI 55–65) among 338 patients hospitalized in three general adult acute psychiatric in-patient units lacked mental capacity to make treatment decisions. Patients with mania or being detained had higher rates of incapacity (9). Despite these results, whether and how mental capacity to con- sent to treatment differs between patients treated voluntarily or involuntarily remains unclear. However, extensive research pro- vided evidence on patients’ capacity to consent to treatment in noncoercive medical and psychiatric settings (10) as well as information on specific tools aimed at investigating mental capac- ity. Such results represent an essential background to guide stud- ies aimed at investigating mental capacity also in coercive psychiatric clinical settings. Several lines of evidence pointed out that a significant association exists between cognitive functioning and mental capacity, and patients with cognitive dysfunctions could be at higher risk of incapacity (11–13). In those psychiatric patients presenting with severe psychiatric symptoms, as do patients hospitalized for acute treatment, symptoms also appear to be negatively associated with decisional capacity (8,14–16). 1 Department of Neurosciences, Mental Health and Sensory Organs, University of Rome “Sapienza”, via di Grottarossa, 1035, 00189 Rome, Italy. 2 Department of Neurology and Psychiatry, University of Rome “Sapienza”, Viale dell’Universita 30, 00185 Rome, Italy. 3 Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, University of Rome “Sapienza”, Viale Regina Elena 336, 00185 Rome, Italy. Received 16 Dec. 2012; and in revised form 1 May 2013; accepted 10 May 2013. 1002 © 2014 American Academy of Forensic Sciences J Forensic Sci, July 2014, Vol. 59, No. 4 doi: 10.1111/1556-4029.12420 Available online at: onlinelibrary.wiley.com