PubMed Health⌕ Search

Biomedical subjects

Paul S Appelbaum

Publications and source records attributed to Paul S Appelbaum.

At least 19 recordsLinked to original sources
PubMed2006

Prevalence and correlates of adequate performance on a measure of abilities related to decisional capacity: differences among three standards for the MacCAT-CR in patients with schizophrenia.

Despite the availability of structured decision-making capacity assessment tools, insufficient guidance exists for applying their results. Investigators often use cutpoints on these instruments to identify potential subjects in need of further assessment or education. Yet, information is lacking regarding the effects of different cutpoints on the proportion and characteristics of individuals categorized as possessing adequate or impaired decisional abilities for consent to research. To demonstrate the potential impact of different standards, we informed 91 individuals, aged 50 or older with a diagnosis of schizophrenia or schizoaffective disorder, about a hypothetical clinical trial, and assessed their decisional abilities with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). Three published MacCAT-CR-based standards were applied to participants' scores to examine the rates and correlates of categorical determinations of adequate performance. The three standards ranged in stringency: the most stringent incorporated cutpoints on all three of the major MacCAT-CR subscales (Understanding, Appreciation, and Reasoning); the other two standards required threshold performance only on the Understanding subscale. The most stringent standard resulted in a 57% rate of impaired performance; the intermediate standard, 19%; and the least stringent standard, 8%. Nearly half of the participants (n=45) were classified as having performed adequately by the least stringent standard yet inadequately by the most stringent. The majority of these 45 were impaired on the Appreciation subscale (n=9), Reasoning (n=15), or both (n=18). Cognitive functioning was correlated with performance status for the more stringent standards. These findings underscore the need for refinement of capacity assessment procedures and for improvements in the use of capacity assessment tools for screening purposes and to assist in categorical capacity determinations.

Aged↗
PubMed2006

Civil commitment in Turkey: reflections on a bill drafted by psychiatrists.

Involuntary hospitalization of the mentally ill has been an issue that still remains outside the judicial system in Turkey. Despite the new Turkish Civil Code, which includes several articles relevant to involuntary psychiatric hospital admissions, there still appears to be a need for a comprehensive mental health law to address specific issues concerning civil commitment of the mentally ill. As a result of the lack of specific statutory regulation, an insufficient number of psychiatric hospital beds and limited appreciation of the safety risks involved in untreated mental illness, involuntary hospitalization remains an underutilized option by psychiatrists and the courts alike. In response to its concerned members, the Psychiatric Association of Turkey has appointed a task force to draft a proposed mental health law, entitled the "Psychiatric Patients' Bill of Rights." Although the draft suggests a model with emphasis on the right to psychiatric treatment, it also recommends close judicial oversight to prevent potential abuses of discretion by the system. However, this might present logistic problems in a country with already overburdened courts. Authors discuss the highlights of the draft within the context of Turkey's current cultural, social and judicial structure, and compare it to similar laws of other countries.

Advisory Committees↗
PubMed2006

The capacity to appoint a proxy and the possibility of concurrent proxy directives.

With the projected increase in the number of persons with dementia (who eventually lose their capacity to give informed consent to treatment and research), third-party decision-making will become even more common than it is today. We argue that, because there are situations in which an appointed proxy is preferred over a de facto surrogate, it is ethically important to understand the capacity of persons with dementia to delegate their decision-making authority regarding treatment and research decisions. In this paper, focusing mainly on the research consent context, we examine the idea that persons suffering from neurodegenerative disorders may retain significant abilities-including sufficient capacity for delegating one's authority for giving consent to research-even if they are not capable of giving independent consent themselves. We first propose a rationale for assessing the capacity to appoint a proxy and then describe a novel interview instrument for assessing the capacity to appoint a proxy for research consent.

Advance Directives↗
PubMed2006

The classification of violence risk.

The Classification of Violence Risk (COVR) is an interactive software program designed to estimate the risk that a person hospitalized for mental disorder will be violent to others. The software leads the evaluator through a chart review and a brief interview with the patient. At the end of this interview, the software generates a report that contains a statistically valid estimate of the patient's violence risk-ranging from a 1% to a 76% likelihood of violence-including the confidence interval for that estimate, and a list of the risk factors that the program took into account to produce the estimate. In this article, the development of the COVR software is described and several issues that arise in its administration are discussed.

Antisocial Personality Disorder↗
PubMed2006

Impact of decisional capacity on the use of leverage to encourage treatment adherence.

Leverage is often applied to persons with mental illnesses who live in the community to encourage them to adhere to treatment. Given the underlying assumption that the targets of such leverage are unable to make good decisions about treatment on their own, one might expect that decisional incapacity regarding treatment would correlate with the use of leverage. As part of a multi-site study of leverage in community treatment, 120 subjects at two sites reported on their leverage experiences and completed a decisional capacity assessment with the MacCAT-T. No strong or consistent associations were found between capacity and use of leverage, raising questions about the basis on which decisions to employ leverage are being made.

Adolescent↗
PubMed2006

Use of leverage over patients' money to promote adherence to psychiatric treatment.

Persons who handle money for patients with mental disabilities often use access to funds as leverage to promote adherence to treatment. Drawing on data from a five-site study involving interviews of 1011 patients at community mental health centers, this paper explores who provides money assistance, the predictors of leverage use, and its impact on patients. A substantial minority of patients reported having experienced leverage. Substance abuse and frequent hospitalization were the strongest clinical predictors, suggesting that functional impairment is a key determinant. Patients experiencing money leverage were also likely to experience other forms of leverage, and although they were more likely to feel coerced, they were also more likely to believe that money leverage was effective. Family members seemed to provoke fewer negative feelings as money managers. The frequency with which money leverage is used suggests attention is needed to both the fairness of leverage and the means of minimizing negative effects.

Adult↗
PubMed2006

Assessment of therapeutic misconception in older schizophrenia patients with a brief instrument.

OBJECTIVE: "Therapeutic misconception," or conflation of goals and procedures of clinical research with those of usual clinical care, is an important topic in research ethics because it may impede informed consent. How best to assess therapeutic misconception is unclear. Also unclear is to what degree patients with severe mental illnesses, such as schizophrenia, may manifest these beliefs. METHOD: With a hypothetical, double-blind, placebo-controlled trial as a stimulus, the authors examined the frequency of a key aspect of therapeutic misconception with a true/false scale in 87 middle-age and older patients with schizophrenia or schizoaffective disorder. They also analyzed the demographic, clinical, neurocognitive, and decision-making correlates of therapeutic misconception and examined the psychometric properties of a scale designed to measure therapeutic misconception. RESULTS: Subjects showed variable performance on the therapeutic misconception measure. Nearly one-third answered all questions correctly; two-thirds answered four or more of the six items correctly. Patients with less education or worse cognitive functioning manifested higher levels of therapeutic misconception. Degree of therapeutic misconception was inversely associated with understanding, appreciation, and reasoning scores on the MacArthur Competence Assessment Tool for Clinical Research but was not associated with severity of psychopathology. The scale showed fair internal consistency. CONCLUSIONS: As in studies of other patient populations, patients with schizophrenia show a substantial incidence of beliefs associated with therapeutic misconception. Further work should focus on refining measures of therapeutic misconception, identifying participants or protocols (e.g., higher-risk studies) in which it may warrant greater concern, and developing educational interventions to mitigate it.

Age Factors↗
PubMed2006

Law & psychiatry: Twenty-five years of law and psychiatry.

Dr. Appelbaum reviews the past 25 years of the Law & Psychiatry column, of which he has been the editor since the column's initiation by John Talbott, M.D. The column has included contributions from Dr. Appelbaum as well as from various other mental health professionals and lawyers with various specializations. Citation of the column in other articles suggests that it is meeting a need for timely description and analysis of major legal developments that affect the field of psychiatry and psychiatric patients. Dr. Appelbaum notes that the 104 columns published thus far reflect the evolution of legal concerns in psychiatry as well as the presence of core issues that have remained unchanged. He raises the question of what the next quarter century will hold, positing that mental health law will continue to reflect a tension between the interests of persons with mental illness and the public's fear of such individuals.

Forecasting↗
PubMed2006

Law & psychiatry: insanity, guilty minds, and psychiatric testimony.

This column describes a recent Supreme Court case, Clark v. Arizona, in which an adolescent who had schizophrenia was convicted of first-degree murder of a police officer who he believed was a hostile space alien. The Arizona courts had rejected his insanity defense as well as a second defense that he lacked the required intent to commit the crime (mens rea) because his delusions interfered with his knowing that the victim was a police officer. The Court ultimately declined to overturn Arizona's rules regarding the insanity defense and mens rea. However, the column highlights the points in Justice Souter's decision that may have implications for any case involving mental health issues.

Adolescent↗
PubMed2006

Law & psychiatry: "depressed? Get out!": dealing with suicidal students on college campuses.

This column examines college and university policies under which students who manifest suicidal ideation are barred from campus, usually by immediate suspension or mandatory withdrawal. Such policies, which appear to be increasing on U.S. campuses, generally reflect administrators' fears of legal liability if students commit suicide on campus. The author reviews two recent cases-Schieszler v. Ferrum College and Shin v. Massachusetts Institute of Technology-that have created a climate of fear among administrators and suggests ways to change blanket policies so that students at low risk of suicide will not be barred from campus and will seek and obtain appropriate treatment.

Adolescent↗
PubMed2006

Commentary: psychiatric advance directives at a crossroads--when can PADs be overridden?

Current statutes enabling psychiatric advance directives (PADs) typically include provisions allowing override of patients' choices by treatment staff. Lest the purpose of the PAD be vitiated by too broad an application of the override mechanism, its use should be carefully limited. In inpatient settings, voluntary patients should have the right to decline treatments in advance, although not an absolute right to demand treatments of their choosing. The situation of involuntary patients is more complex. Permitting PADs to trump commitment statutes would undercut the combined parens patriae/police power rationale for commitment, a path taken currently by no U.S. jurisdiction. Moreover, PADs should not be permitted to negate the usual mechanisms for involuntary treatment of committed patients; to do otherwise risks forcing facilities to confine indefinitely persons they cannot treat. Even in those circumstances, however, where PADs provide evidence of reasonable patient preferences (e.g., for one medication over another), the choices they embody should be respected.

Advance Directives↗
PubMed2005

Evaluation of "subject advocate" procedures in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study.

Because the decision-making capacity of individuals with schizophrenia may fluctuate, additional protections for such persons who enroll in long-term research studies may be needed. For the NIMH-sponsored Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study, new procedures were developed to help ensure an objective assessment of a patient's continued participation in the study if decision-making capacity lapsed. Each research participant had a subject advocate who could recommend that the subject be withdrawn from the study if capacity lapsed and continued participation was not in the subject's best interest. The main goals of the procedures were to protect the interests of subjects and to prevent unnecessary dropouts. We surveyed research personnel regarding the effectiveness and implementation of the procedures. Responses were received from 73 personnel at 49 research sites, representing 70% of possible respondents and 91% of eligible sites. A majority of respondents were favorably disposed toward subject advocates, and though most reported that the procedures had no discernible effect on study recruitment, subject autonomy, or subject retention, for those who reported an impact, it was almost always positive. Some respondents reported that the procedures helped by engaging family members and promoting a positive view of schizophrenia research. A majority thought that similar arrangements would be useful in future longitudinal research studies. Nonspecific benefits included good public relations and engagement of family members. Improved training regarding the procedures may be needed to achieve specific goals of enhanced patient autonomy and retention in the study.

Antipsychotic Agents↗
PubMed2005

Willingness of subjects with thought disorder to participate in research.

Greater attention is being focused on the willingness and motivations of potential subjects who are recruited for research protocols. Given the importance of subjects' abilities to choose freely and reason through their decisions about entering psychiatric research, empirical researchers have been developing assessment and education tools that address the potential vulnerabilities of research subjects. In this study subjects' responses and reasons for or against participation were elicited as part of an assessment of their research decision making. Fifty-two persons diagnosed with a thought disorder were asked to consider a hypothetical research study using the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). Their responses were documented, coded for content, and correlated with demographic characteristics and scores on scales rating psychosis, cognition, and health-related quality of life. Subjects expressed common considerations that have been identified by other psychiatric investigators, as well as by those studying nonpsychiatric protocols. In general, reasons were both appropriate to the study being considered and appropriately linked to common considerations that flowed logically from the study. However, elements of the therapeutic misconception were evident as well. Willingness to participate was correlated with higher MacCAT-CR scores on certain scales, better education, and lower levels of psychosis and cognitive impairment. These findings highlight both the strengths and weaknesses of the decision making of research subjects with thought disorder. Research protections and assessments may consequently be appropriately targeted to specific vulnerabilities. Because of differences in severity of illness, cognition, and reasoning among subjects who decline to participate in research, greater attention to this population appears warranted.

Adult↗
PubMed2005

Decisional capacity of patients with schizophrenia to consent to research: taking stock.

With the growth in recent years of studies of decisional capacity for research among people with schizophrenia, this is an opportune time to ask three questions: What have we learned from these studies? What remains to be learned? And what normative issues still need to be resolved? Among the things learned are that patients with schizophrenia, as a group, have lower scores on measures of decisional capacity than normals, but higher performance than patients with dementia. However, performance is highly variable within the group, correlates most strongly with neuropsychological impairment, and seems susceptible in many patients to successful remediation. The issues that remain in need of exploration include the development of a brief screening instrument for decisional capacity that can be used routinely, and the identification of those patients most likely to benefit from more intensive informational procedures. Finally, among the normative issues still in need of resolution are the degree of capacity needed to consent to research participation, how to deal with fluctuating capacity during research projects, and the legitimate extent of surrogate consent for participation of incompetent patients in research.

Biomedical Research↗
PubMed2005

Assessment of capacity to consent to research among older persons with schizophrenia, Alzheimer disease, or diabetes mellitus: comparison of a 3-item questionnaire with a comprehensive standardized capacity instrument.

CONTEXT: Considerable discussion surrounds issues related to the capacities of neuropsychiatric patients to consent to research, yet few empirical investigations have directly compared decisional capacity among patients with a serious mental illness with that among patients with neurologic or medical conditions. Also, as requirements for formal assessment of decisional capacity are becoming more common, there is a clear need to identify efficient screening methods. OBJECTIVES: To compare decisional capacity among 3 diagnostic groups, and to examine the degree to which impaired understanding can be detected with a brief set of screening questions. SETTING: Outpatient veterans hospital clinic and university-based neuropsychiatric research centers. DESIGN/ PARTICIPANTS: Cross-sectional comparison of decisional capacity among older (>/=60 years) outpatients with schizophrenia (n = 35), mild to moderate Alzheimer disease (n = 30), and type 2 diabetes mellitus (n = 36), and determination of sensitivity and specificity of a screening measure. MAIN OUTCOME MEASURES: Three-item decisional capacity questionnaire and the MacArthur Competence Assessment Tool for Clinical Research. RESULTS: Patients with diabetes mellitus performed the best on the capacity instruments, patients with Alzheimer disease had the worst performance, and patients with schizophrenia were intermediate. However, there was considerable heterogeneity within each group. Even within diagnostic groups, the level of cognitive functioning (measured with the Mini-Mental State Examination) was generally the best predictor of decisional capacity (particularly in the understanding component). The 3-item questionnaire was sensitive to impaired understanding as measured with the MacArthur Competence Assessment Tool for Clinical Research understanding subscale. CONCLUSIONS: Decisional capacity differed among the 3 groups; there was considerable heterogeneity even within each diagnostic group, so individualized consideration of capacity may be warranted. The level of cognitive deficits is 1 potential marker of which participants should receive comprehensive capacity evaluations, but sensitive brief questionnaires targeting key aspects of disclosed information may also provide an effective means of screening for participants warranting comprehensive capacity evaluations.

Age Factors↗