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Alec Buchanan

Publications and source records attributed to Alec Buchanan.

12 recordsLinked to original sources
PubMed2006

The inter-rater reliability of mental capacity assessments.

BACKGROUND: Assessing mental capacity involves complex judgements, and there is little available information on inter-rater reliability of capacity assessments. Assessment tools have been devised in order to offer guidelines. We aimed to assess the inter-rater reliability of judgements made by a panel of experts judging the same interview transcripts where mental capacity had been assessed. METHOD: We performed a cross sectional study of consecutive acute general medical inpatients in a teaching hospital. Patients had a clinical interview and were assessed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and Thinking Rationally About Treatment (TRAT), two capacity assessment interviews. The assessment was audiotaped and transcribed. The raters were asked to judge whether they thought that the patient had mental capacity based on the transcript. We then divided participants into three groups - those in whom there was unanimous agreement that they had capacity; those in whom there was disagreement; and those in whom there was unanimous agreement that they lacked capacity. RESULTS: We interviewed 40 patients. We found a high level of agreement between raters' assessments (mean kappa=0.76). Those thought unanimously to have capacity were more cognitively intact, more likely to be living independently and performed consistently better on all subtests of the two capacity tools, compared with those who were unanimously thought not to have capacity. The group in whom there was disagreement fell in between. CONCLUSIONS: This study indicates that clinicians can rate mental capacity with a good level of consistency.

Cardiovascular Diseases↗
PubMed2006

Paranoia in the criminal courts.

It is generally accepted that those who suffer from mental illness are less responsible for their criminal actions than others. A fictitious case of a woman suffering from a paranoid psychosis, who severely injures her legal advisor, is considered in two different but related jurisdictions, England & Wales and Connecticut, USA. Four elements of the criminal process are considered. Significant differences between the jurisdictions are found in all four elements. There is greater pragmatism in the English system and a greater chance of the woman ending up in long-term hospital care, but both systems aim to prevent further violence by the use of institutionalisation. International and intra-national variations in the care of this hypothetical woman are briefly discussed, and it is clear that in both countries medical care is compromised by attitudinal and political considerations.

Criminal Law↗
PubMed2006

Quantifying the contributions of three types of information to the prediction of criminal conviction using the receiver operating characteristic.

BACKGROUND: Quantifying the contributions that different types of information make to the accurate prediction of offending offers the prospects of improved practice and better use of resources. AIMS: To quantify the contributions made by three types of information--demographic data alone, demographic and criminal record and demographic, criminal record and legal class of disorder--to the prediction of criminal conviction in patients. METHOD: All 425 patients discharged from the three special (high secure) hospitals in England and Wales over 2 years were followed for 10.5 years. The contribution of each type of information was described in terms of the area under the receiver operating characteristic curve (AUC) and the number needed to detain (NND). RESULTS: The AUC values using the three types of information were 0.66, 0.72 and 0.73 respectively. Prediction based on the full model using an optimal probability cut-off implies an NND of 2. The AUCs for serious offences were 0.67, 0.69 and 0.75 respectively. CONCLUSIONS: For long-term prediction of conviction on any charge, information on legal class adds little to the accuracy of predictions made using only a patient's age, gender and criminal record. In the prediction of serious offences alone the contribution of legal class is significant.

Adolescent↗
PubMed2006

Psychiatric evidence on the ultimate issue.

Federal Rule of Evidence 704(b) prevents psychiatrists and other expert witnesses in federal criminal trials from testifying as to whether a defendant did or did not have a mental state or condition comprising either an element of the crime or an element of the defense. This paper describes the origins of the Rule and its judicial development. The Rule is an exception to a 20th century trend that has seen witnesses increasingly permitted to address the ultimate issue. It has been applied inconsistently, has been criticized in appellate decisions, and has spawned an idiosyncratic legal definition of "helpful." Attempts to circumvent it have included inviting jurors to make inferences, inventing hypothetical cases that mimic the one before the court, and eliciting expert testimony on what is "possible" or "probable." Courts have held that rendering transparent the reasons behind an expert's conclusions can minimize the damage done by ultimate issue testimony.

Expert Testimony↗
PubMed2006

Competency to stand trial and the seriousness of the charge.

Authorities disagree as to whether and how the mental capacity required for competence to stand trial should change as the charges against a defendant become more serious. Intuition and practice in other areas of law and psychiatry suggest that the mental capacity required should increase in these circumstances. The reasons relate to our belief that serious mistakes are more to be avoided and to a principle of "proportionality," according to which the threshold level of capacity required is derived, in part, from the consequences of a person's being found competent. The article compares two approaches to "proportionality." The conclusions have implications for the wording of examiners' conclusions and for the criteria by which patients are regarded as "restored to competence."

Capital Punishment↗
PubMed2005

Reliability of mental capacity assessments in psychiatric in-patients.

BACKGROUND: Previous work on the reliability of mental capacity assessments in patients with psychiatric illness has been limited. AIMS: To describe the interrater reliability of two independent assessments of capacity to consent to treatment, as well as assessments made by a panel of clinicians based on the same interview. METHOD: Fifty-five patients were interviewed by two interviewers 1-7 days apart and a binary (yes/no) capacity judgement was made, guided by the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Four senior clinicians used transcripts of the interviews to judge capacity. RESULTS: There was excellent agreement between the two interviewers for capacity judgements made at separate interviews (kappa=0.82). A high level of agreement was seen between senior clinicians for capacity judgements of the same interview (mean kappa=0.84). CONCLUSIONS: In combination with a clinical interview, the MacCAT-T can be used to produce highly reliable judgements of capacity.

Adult↗
PubMed2005

Prevalence and predictors of mental incapacity in psychiatric in-patients.

BACKGROUND: Little is known about the proportion of psychiatric in-patients who lack capacity to make treatment decisions, or the associations of lack of capacity. AIMS: To determine the prevalence of psychiatric in-patients who lack capacity to make decisions about current treatment and to identify demographic and clinical associations with lack of mental capacity. METHOD: Patients (n=112) were interviewed soon after admission to hospital and a binary judgement of capacity was made, guided by the MacArthur Competence Tool for Treatment. Demographic and clinical information was collected from an interview and case notes. RESULTS: Of the 112 participants, 49 (43.8%) lacked treatment-related decisional capacity. Mania and psychosis, poor insight, delusions and Black and minority ethnic group were associated with mental incapacity. Of the 49 patients lacking capacity, 30 (61%) were detained under the Mental Health Act 1983. Of the 63 with capacity, 6 (9.5%) were detained. CONCLUSIONS: Lack of treatment-related decisional capacity is a common but by no means inevitable correlate of admission to a psychiatric in-patient unit.

Adult↗
PubMed2004

Mental capacity, legal competence and consent to treatment.

Deciding whether someone is legally competent to make decisions regarding their own treatment requires an assessment of their mental capacity. The assessed capacity required for legal competence increases with the seriousness of what is at stake. The usual explanation is that patient autonomy is being balanced against best interests. An alternative explanation, that we require greater room for error when the consequences are serious, implies a change to clinical practice and in the evidence doctors offer in court.

Ethics, Medical↗
PubMed2002

The eye of the beholder: ratings of risk using a reliable instrument and identical clinical material.

Risk management is increasingly seen as a task for health professionals. However little is known about how different professionals perceive and rate risk. The purpose of this study was to see if professional background and experience influence how an assessor rates risk. Psychiatric staff were presented with identical clinical information about one case. They were then asked to score the HCR-20. This is a structured clinical assessment and gives a score of between 0 and 40. Higher scores indicate increased risk of future violence. There was a twofold variation in the score from 15 to 30. There was no difference between medical and non-medical staff. However there was a significant difference between different grades of psychiatrists. Senior psychiatrists scored the clinical and risk items significantly lower when compared with junior psychiatrists. There was no significant difference in the scoring of historical items. The twofold variation in the score on the HCR-20 emphasises that risk assessment is a two-way process. Individual differences of assessors may be very important. Our findings suggest that senior psychiatrists score risks as lower. Possible explanations are discussed.

Attitude of Health Personnel↗
PubMed2002

Violence and schizophrenia: examining the evidence.

BACKGROUND: It is now accepted that people with schizophrenia are significantly more likely to be violent than other members of the general population. A less acknowledged fact is that the proportion of societal violence attributable to schizophrenia is small. AIMS: To critically examine the epidemiological evidence for the association between violence and schizophrenia and estimate the impact of this association on society. METHOD: A selective review of the key literature on the epidemiology of violence and schizophrenia. Population-attributable risks for violence in schizophrenia are calculated from population-based studies. RESULTS: Most studies confirm the association between violence and schizophrenia. Recent good evidence supports a small but independent association. Comorbid substance abuse considerably increases this risk. The proportion of violent crime in society attributable to schizophrenia consistently falls below 10%. CONCLUSIONS: Less focus on the relative risk and more on the absolute risk of violence posed to society by people with schizophrenia would serve to reduce the associated stigma. Strategies aimed at reducing this small risk require further attention, in particular treatment for substance misuse.

Bias↗
PubMedDate not supplied

Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study.

BACKGROUND: Although mental incapacity is becoming increasingly important in clinical practice, little information is available on its frequency in medical inpatients. We aimed to estimate the prevalence of mental incapacity in acutely admitted medical inpatients; to determine the frequency that medical teams recognised patients who did not have mental capacity; and to identify factors associated with mental incapacity. METHODS: Over an 18-month period, we recruited 302 consecutive acute medical inpatients. Participants were assessed with the MacArthur competence tool for treatment and by clinical interview. Cognitive impairment was measured by the mini-mental state examination. FINDINGS: 72 (24%) patients were severely cognitively impaired, unconscious, or unable to express a choice and were automatically assigned to the incapacity group. 71 (24%) refused to participate or could not speak English. Thus, 159 patients were interviewed. Of these, 31% (95% CI 24-38) were judged not to have mental capacity. For the total sample (n=302), we estimated that at least 40% did not have mental capacity. Clinical teams rarely identified patients who did not have mental capacity: of 50 patients interviewed, 12 (24%) were rated as lacking capacity. Factors associated with mental incapacity were increasing age and cognitive impairment. INTERPRETATION: Mental incapacity is common in acutely ill medical inpatients, and clinicians tend not to recognise it. Screening methods for cognitive impairment could be useful in detecting those with doubtful capacity to consent.

Acute Disease↗