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Understanding treatment decision-making capacity in psychosis

Many people with psychosis are judged to lack the capacity to make their own decisions about their care. However we don't really understand what causes this. This prevents us from being able to effectively support them to make their own decisions. Being judged to lack capacity means a person will no longer have the autonomy to refuse or accept a particular treatment, which for people with psychosis will often involve inpatient care and antipsychotic medication. This loss of autonomy can be highly traumatic and disempowering.


For these reasons we set out to develop and test a sophisticated theoretical model of the factors that help or hinder capacity in this group, with the longer-term aim of developing effective, safe and acceptable psychological interventions to restore and support it.

Stovell, Wearden, Morrison & Hutton (2014)

  • We did a qualitative study (N=7) of people with multiple experiences of compulsory treatment for psychosis.

  • In-depth interviews confirmed the importance of developing a psychologically informed assessment of capacity that takes into account service user values and goals around recovery, the potentially traumatising impact of involuntary treatment on people with psychosis, and the role of treatment-related social defeat in capacity and treatment decision-making experiences.

  • The paper is available here

Stovell, Morrison, Panayitou & Hutton (2015)

  • We completed a systematic review and meta-analysis of 11 randomised controlled trials of shared treatment decision-making, and found it had small positive effects on subjective empowerment in psychosis.

  • Although there was a trend towards reduced compulsory care for those who received shared treatment decision-making, the evidence regarding its effects on treatment decision-making capacity was limited and mixed.

  • Notably shared treatment decision-making is quite a different paradigm to supported treatment decision-making. Although clinicians are reluctant to use shared decision-making if person lacks capacity, they may be prepared to use supported decision-making.

  • The paper is available here

Larkin & Hutton (2017)

  • We did a systematic review and meta-analysis of 23 studies (N=1823) which examined the association between treatment decision-making capacity in psychosis and a range of factors. This work highlighted the near absence of research on psychological or emotional factors in impaired capacity in psychosis, although some early findings indicated the importance of metacognitive awareness of cognitive impairments and bias on capacity.

  • We found that symptoms, cognitive impairment, education and insight have all been studied extensively, and are associated with capacity in the expected direction.

  • No clear relationship between depression and capacity was found, and greater anxiety was associated with better capacity.

  • Other than trials of shared decision-making, the only other attempt to improve capacity was a small non-randomised trial of metacognitive training, which reported large improvements in understanding and reasoning following the intervention.

  • The paper is available here

Larkin, Turner, Whyte & Hutton (in prep)

  • This was a cross-sectional study of 25 individuals with psychosis. We found the jumping to conclusions bias was correlated with the understanding domain of capacity, and may also contribute to reduced appreciation, after controlling for the contribution of cognition, symptoms and insight.

  • We found that positive symptoms appeared to mediate the relationship between the jumping to conclusions bias and capacity. This suggests this bias contributed to positive symptoms, which in turn contributed to reduced understanding.

  • We found no significant relationship between capacity and either depression or subjective recovery.

Sparks, Woodrow, Bobrovskaia & Hutton (under review)

  • We did a systematic review and meta-analysis of 37 studies (N=2935), and found the general decision-making performance of people with psychosis - as measured by performance on the Iowa Gambling Task or similar measures - was impaired relative to healthy individuals. Very few studies had compared their performance to people with non-psychotic mental health problems, meaning the specificity of this impairment to psychosis remains unclear.

  • We found their decision-making performance was only weakly associated with negative symptoms, and no association with positive symptoms, executive functioning or education was observed.


Hutton, Murphy, Turner, Woodrow, Sparks & Larkin (in prep)

  • We have integrated these findings into a theoretical model of impaired treatment capacity in psychosis. The model proposes there are three pathways to impaired treatment decisional capacity in psychosis.

  • Pathway 1 involves appraisals of intrusive internal and adverse external events

  • Pathway 2 involves direct effects on capacity of cognitive perseveration, biases and impairment

  • Pathway 3 involves emotional arousal, caused by perseveration and appraisals

  • Building on previous research, we propose metacognition moderates the effects of cognitive perseveration and impairments on capacity.

In order to test this model and develop interventions to support capacity in psychosis, we have started to run clinical trials.

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