Mental Capacity and Advance Directive of Persons with Mental Illness: A Descriptive Cross-sectional Study from India

Abstract

Background:

For persons with mental illnesses (PWMI), mental capacity (MC) refers to their ability to perceive, choose, and articulate their treatment options. An advance directive (AD) is a declaration stating a person’s wishes for care if their mental condition renders them handicapped. It also permits them to designate a nominated representative (NR) to assist them in making treatment-related decisions. The study aimed to ascertain the MC for treatment decisions, including admission of Indian PWMI, and analyze their AD.

Methods:

This was a descriptive, exploratory, cross-sectional study involving 74 PWMI. The Clinical Global Impression–Severity (CGI-S) scale, “Capacity Assessment for Treatment Decisions Including Admission,” the Bengaluru Advanced Directive Interview (BADI), and the Insight and Treatment Attitudes Questionnaire (ITAQ) were used to assess the severity of illness, MC, AD, and insight, respectively.

Results:

The majority of PWMI (N = 66, 89.18%) had MC and were able to make choices regarding their admission, care, and treatment for mental health issues. Twelve patients who did not receive AD for treatment believed that in the future, they would never have any mental illness. The MC was significantly related to gender and insight (p values .020 and .001, respectively). Regarding AD, patients predominantly chose outpatient care (55.38%) and management by psychiatrists (78.38%) over other treatment providers. Mainly, parents (55.4%) were selected as NRs.

Conclusions:

The majority of the Indian PWMI had MC and provided AD. The MC was significantly related to insight. According to current regulations, when providing care for PWMI, MC, and AD should be routinely assessed and documented.

Keywords

Advance Directive (AD)India Mental Capacity (MC)Mental Health Care Act 2017 (MHCA 2017)Mental Illness

Key Messages:

Question: For Indian persons with mental illnesses, how does one determine the mental capacity for treatment decisions, including admission, and analyze their advance directives?

Findings: The majority of PWMI had intact MC. The MC was significantly related to gender and insight. Regarding advance directives, patients predominantly chose outpatient care, opted for parents as nominated representatives, and preferred management by psychiatrists.

Meaning: There is a need to develop and standardize an Indian metric-based assessment tool for mental capacity.

India’s ratification of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD),¹ necessitated the need for a rights-based, biopsychosocial model of disability, which was endorsed in the Rights of Persons with Disabilities (RPwD) Act, 2016.² The RPwD Act recognizes mental illness as a disability and includes various rights, and emphasizes that government must ensure that people with disabilities have the same rights as everyone else, including equality, a dignified living, and respect for their integrity. To align with the UNCRPD, in India, the Mental Health Care Act, 2017 (MHCA, 2017),³ seeks to uphold, defend, and promote such individuals’ rights when delivering mental health care and services to patients with mental illnesses (PWMI). The MHCA 2017 affirms the provision of mental healthcare and services to PWMI, as well as safeguarding, advocating for, and implementing their rights while providing such care and services. The very essence of this regulation is in Chapter 5, which ensures patients’ rights to access various mental healthcare facilities. The statute aims to guarantee that mental healthcare facilities are accessible to everybody, and focuses on “autonomy.”⁴

For PWMI, the MHCA 2017 outlines the concepts of mental capacity (MC) and advance directive (AD). As per Chapter II and Section 4 of the MHCA 2017, the MC is the capacity of a person with mental illness to understand, decide on their treatment, and communicate the same. The MC is in reference to mental health care, which comprises evaluating and diagnosing a mental illness, as well as managing, caring for, and rehabilitating an individual with a diagnosed or probable mental disease.⁵ This necessitates a comprehensive evaluation of capacity for everybody receiving mental health treatment at the point of admission. If the following requirements are met, an individual is considered to have MC (Section 4, Chapter II of MHCA): “(a) Understanding of relevant information to make a decision regarding treatment, admission, or personal assistance, (b) appreciation of reasonably foreseeable consequence of a decision or a lack of decision regarding the mental health care, and (c) communication of the decision by any means.” Under the MHCA, determining capacity for mental healthcare choices is independent of the categorization of the mental illness in question.⁵

The MHCA 2017 allows a person to issue an AD.⁴ The AD means a directive made by any person under Section 5 of the MHCA 2017, and is a written declaration that describes “how they want to be cared” for and “how they should not be cared for” if they become disabled due to their mental illness; additionally, the individual (except children) can select an nominated representative (NR) to help him or her make treatment-related choices.³ The ADs can enable patients to make the decisions regarding their treatment and care; it can lead to less perceived coercion and also improved treatment adherence.⁶ It also encourages patients to preselect the treatment in case a future crisis arises.⁷ An Indian study,⁸ showed that irrespective of education and domicile, psychotic patients with long-term illness could make valid ADs. Patients also demonstrated a high level of self-efficacy, selecting active, passive, and collaborative treatment options based on the situation.⁹ Pathare et al.,¹⁰ found that most users agreed to formulate AD and were comfortable appointing an NR. While these studies confirm the utility of ADs in clinical practice, the Cochrane meta-analysis,¹¹ opined that there is currently insufficient evidence to advocate advanced treatment directives for individuals with serious mental illnesses. In this meta-analysis, no significant difference in inpatient stays or outpatient visits was observed between those receiving advanced treatment directions and those receiving standard care. Likewise, there were no significant differences in treatment adherence, self-injurious behavior, or arrest frequency. Individuals receiving advanced treatment directions required less time from social workers than the standard care group, and violent behaviors were lower as well in the advanced directives group. Hence, the evidence is mixed.

Insight encompasses three distinct yet related aspects: (a) An individual’s acknowledgment of receiving a diagnosis of a mental illness, (b) the recognition that treatment is needed to manage the illness, and (c) the ability to re-label the experienced symptoms as aberrant and a component of the illness.¹² Patients with psychotic disorders (such as schizophrenia) are often thought to have less insight than people with neurotic diseases. However, according to experts, insight does not help differentiate between psychosis and neurosis because both diseases can exhibit both good and a lack of insight.^13–15

The Rationale for the Study

There are very few published Indian studies regarding MC and AD. An Indian study,¹⁶ assessed MC in acutely ill patients; however, the authors used the MacArthur Competence Assessment Tool for Treatment (MacCAT-T).¹⁷ Though the MacCAT-T is regarded as the gold standard for capacity assessment, it is not standardized for the Indian population.^16,18 Family plays a vital role in healthcare decision-making in Asian countries.¹⁹ In India, where family is highly emphasized, there can be many difficulties in determining the AD of patients and enabling them to make decisions about future treatment modalities. With the advent of MHCA 2017, for both practical and medicolegal reasons, it is critical to understand, have knowledge, assess, and document both MC and AD of PWMI for managing their mental illness. Hence, the current study aimed to determine the MC and ADs of Indian persons with mental illness. The objectives were: In Indian persons with mental illness, (a) to determine the MC, (b) to explore ADs, and (c) to analyze the relationship between the “MC” and “insight regarding the illness and attitude toward the treatment.”

Methods

Study Design and Sample

This was a descriptive exploratory cross-sectional study conducted at the Institute of Mental Health, Department of Psychiatry, Osmania Medical College, Hyderabad, Telangana, India. This 600-bed government-funded tertiary care public teaching psychiatric hospital serves patients from nearby rural and urban areas and also neighboring states. It offers emergency, outpatient, inpatient, community, consultation-liaison, and forensic services to patients with a variety of mental health conditions, including substance use disorders.

All consecutive PWMI presenting to the outpatient department for treatment, between 1 September 2019 and 31 October 2019, aged 18 years and above, who provided written informed consent to participate in the study, were included. They should have been treatment-naïve or not on treatment for at least one year. The mental illnesses were diagnosed by board-certified psychiatrists with extensive clinical and teaching experience, according to the International Classification of Diseases, 10th Revision (ICD-10).²⁰ Based on clinical interview (ICD-10 diagnostic criteria), we excluded those with intellectual disability, personality disorders (either as a single diagnosis or co-morbid to mental illness), dementia, and delirium. Persons with excitement and those who were uncooperative and non-consenting were also excluded from the study.

Tools

The following assessments were conducted upon the patients’ presentation to the hospital’s outpatient department.

Clinical Global Impression–Severity Scale²¹

The Clinical Global Impression–Severity (CGI-S) is a clinician-rated instrument for assessing illness severity and was used to rate illness severity.

Capacity Assessment Guidance Document²²

The MC was assessed by the “Capacity Assessment Guidance Document (CAGD)” developed by the Expert Committee appointed by the Central Mental Health Authority as per Section 81 of the MHCA 2017. The CAGD evaluates the ability to make decisions about mental health care and treatment, and is a semi-structured interview that records the findings of the capacity assessment. The comprehensive evaluation, including behavioral observation, clinical findings, mental state examination, and diagnosis, forms the framework for the ultimate determination of MC. An inquiry about an apparent lack of capacity (such as a patient who is belligerent, agitated, catatonic, stuporous, delirious, under substance or alcohol intoxication, or experiencing profound withdrawal) is part of the CAGD. The following three considerations apply if there is not an apparent lack of capacity; (a) the ability to comprehend information necessary to make decisions about treatment, admission, or personal assistance is evaluated; (b) the ability to recognize the likely outcomes of a decision—or lack thereof—on treatment, admission, or personal assistance; and (c) the capability to communicate one’s choice through speech, expression, gesture, or any other method. The evaluator may offer a final decision on whether a PWMI has the capacity to make treatment decisions or requires complete assistance from an NR.

Bengaluru Advanced Directive Interview²³

The ADs were assessed using Bengaluru Advanced Directive Interview (BADI), a semi-structured, interviewer-rated tool that was validated in two studies. It has a good reliability (Cronbach’s alpha = 0.69) for the negative desires (treatment refusals) of ADs and an acceptable reliability (Cronbach’s alpha = 0.58) for the positive wishes (positive treatment choices) of ADs. The initial investigation revealed a normal distribution, and the final assessment of scale reliability, incorporating all items, was fair to good (Cronbach’s alpha = 0.65).

Insight and Treatment Attitudes Questionnaire²⁴

The insight was evaluated using the Insight and Treatment Attitudes Questionnaire (ITAQ), an 11-item, clinician rating scale designed to assess the patient’s awareness of mental illness and the need for treatment. It has a high interrater reliability (r = 0.82, p < .001) and good construct validity (r = 0.85, p < .001). Though initially standardized for psychotic disorders, such as schizophrenia, it has been used for other mental illnesses as well.^25,26

Ethical Considerations

The study commenced after obtaining approval from the Institutional Ethics Committee of Osmania Medical College, Hyderabad, India, and written informed consent was obtained from the participants and their legally authorized representatives.

Statistical Analysis

As this was a descriptive, naturalistic, exploratory study of treatment-seeking persons presenting consecutively to the outpatient department, no sample size calculation was performed. The data were compiled and analyzed using Jupyter Notebook.²⁷ A Chi-square test was performed to find the significance of different variables concerning the MC. Descriptive analysis of the data collected regarding AD was performed.

Results

Sample Characteristics

Out of 110 subjects screened, 36 were excluded; reasons being: Uncooperative (excitement-12, drowsiness-5), not in a position to give consent (intellectual disability-2, dementia-5, delirium-8), or fulfilling exclusion criteria (personality disorders-4). The final study sample consisted of 74 participants, with a male preponderance (n = 50, 67.56%) and a mean age of 33.45 (±10.53) years. The oldest study participant was 65 years old.

According to the CAGD, 66 (89.19%) of the 74 PWMI had MC and were able to make decisions about their mental health care and treatment, including admission. Fifty-seven (77.02 %) of 74 persons had a past history of mental illness, and this was not significantly related to their MC (p value = .763; chi-square = 0.09). Thirty-six (48.64%) persons had a past history of substance use, and this was not significantly related to MC (p value = .297; chi-square = 1.08). The CGI-S score of the sample was 3.7 ± 0.81. The total ITAQ score was 15.04 ± 5.48, indicating an awareness of illness and attitude toward treatment of 5.7 ± 3.01 and 9.29 ± 2.83, respectively. Table 1 provides details on the socio-demographic data and illustrates the proportions of PWMI with MC and those who declined the need for treatment in the future. Table 2 details patients with MC and those who choose not to undergo treatment in the future, by diagnosis. The PWMI who chose not to undergo future treatment showed statistically significant results concerning their MC (p value = .025; chi-square = 5.00). They also showed statistically significant results concerning their education (p value = .056 and chi-square = 10.73). The statistical significance of various parameters related to ITAQ scores is presented in Table 3.

Table 1.

Socio-demographic Details of the Study Sample (Chi-square Test).

Variable	Total (n = 74)	MC (Present) (n = 66)	Not Choosing Further Treatment and an AD and an NR (n = 12)	Statistical Significance for MC
Variable	N (%)	N (%)	N (%)	p Value
Gender				.020 ^*
Male	50 (67.56)	48 (72.72)	7 (58.3)
Female	24 (32.43)	18 (27.27)	5 (41.7)
Domicile				.702
Rural	55 (74.32)	49 (74.24)	8 (66.6)
Urban	19 (25.67)	17 (25.75)	4 (33.4)
Current marital status				.454
Married	39 (52.70)	34 (51.51)	6 (50)
Never married/divorced/separated/widowed	35 (47.30)	26 (49.39)	6 (50)
Current occupational status				.562
Unemployed	26 (35.2)	24 (36.36)	4 (33.3)
Unskilled	16 (21.6)	13 (19.69)	3 (25.0)
Semiskilled	26 (35.2)	24 (34.83)	4 (33.3)
Professional	6 (8.01)	6 (9.09)	1 (8.33)
Socioeconomic status				.646
Lower	64 (86.48)	57 (86.36)	8 (66.6)
Middle	10 (13.51)	9 (13.63)	4 (33.4)
Education				.499
Illiterate	12 (16.2)	11 (16.16)	1 (8.3)
Primary	13 (17.5)	12 (18.18)	3 (25)
Secondary	22 (29.7)	18 (27.27)	1 (8.3)
Higher secondary	08 (10.8)	08 (12.12)	0 (0)
Degree	16 (21.6)	14 (21.21)	6 (50)
Postgraduation	03 (4.0)	3 (4.54)	1 (8.3)

^*p value < .05 (statistically significant).

MC: Mental capacity, AD: Advance directive, NR: Nominated representative.

Table 2.

Details of the Patient Having the Mental Capacity (MC) and Patients Choosing Not to Take Treatment in the Future, Based on the Various Diagnoses.

Diagnosis	Total (n = 74) N (%)	MC (Present) (n = 66) N (%)	Not Choosing Further Treatment (n = 12) N (%)
Schizophrenia	35 (47.3)	28 (80)	7 (58.3)
Bipolar affective disorder–mania	21 (28.3)	20 (95.23)	4 (38.3)
Alcohol dependence syndrome	13 (17.5)	13 (100)	1 (8.3)
Depressive disorder*	3 (4.0)	3 (100)	0 (0)
Benzodiazepine dependence syndrome	2 (2.7)	2 (100)	0 (0)

*Including Bipolar Affective Disorder–Depression.

Table 3.

Statistical Significance of Various Parameters Concerning the Insight and Treatment Attitudes Questionnaire (ITAQ) Scores (Chi-square Test).

Variable	Statistical Significance
Variable	ITAQ–Awareness of Illness p Value	ITAQ–Attitude Toward Treatment p Value	ITAQ–Total p Value
Marital status	.376	.001*	.004*
Psychiatric history	.058	.011*	.050
Socioeconomic status	.032*	.012*	.002*
MC	.001*	.001*	.001*

*p value < .05 (Statistically Significant).

Regarding the choice of treatment for mental illness in the future, on BADI, Table 4 shows the preferences of PWMI in terms of the treatment settings and the treating person. Most PWMI chose treatment in a mental health establishment (MHE) rather than a general hospital psychiatric unit (GHPU). A larger number of PWMI preferred outpatient care to inpatient management. The BADI proposes five treatment modalities: Injections, medicines, psychotherapy, electroconvulsive therapy (ECT), and psychosurgery. Table 5 presents patients’ choices regarding treatment modalities and caretakers. Twelve (16.22%) of 74 PWMI neither gave AD nor chose NR. These 12 PWMI believed they would not develop the disease in the future. Among all available options, and when given the option to choose multiple, none of the study patients chose their daughter or an office colleague as their NR.

Table 4.

Advanced Directives Concerning Treatment Setting and Treating Person on Bengaluru Advanced Directive Interview (BADI).

Treatment Setting			Treatment Person
Setting	Number	% (Out of 74)^a	Treating Person	Number	% (Out of 74)^a
MHE–OPD	16	21.62	Psych	58	78.38
MHE–IPD	10	13.51	Phys	20	27.03
MHE–IPD + OPD	14	18.91	Phys + psych	14	18.91
GHPU–OPD	5	6.75	Ayush	9	12.16
GHPU–IPD	2	2.70	FH	10	13.51
GHPU–OPD + IPD	2	2.70	FH+ psych	6	8.11
MHE + GHPU (OPD + IPD)	4	5.40	Phys + psych + FH	3	4.05
			FH + Phys	1	1.35

*The total does not add up to 100% (74) as some patients provided multiple options.

12 patients (16.21%) did not choose AD.

FH: Faith healer, GHPU: General hospital psychiatric unit, IPD: Inpatient department, MHE: Mental health establishment, OPD: Outpatient department, Phys: Physician, Psych: Psychiatrist.

Table 5.

Advance Directives Concerning Modalities of Treatment and Choice of Future Caregiver on Bengaluru Advanced Directive Interview (BADI).

Modalities of Treatment
Modality	N	% (Out of 74)*
Pharmacotherapy: Oral medicines	64	86.49
Pharmacotherapy: Oral medicines + injections	46	62.16
Psychotherapy	16	21.62
Psychosurgery	29	39.19
Electroconvulsive therapy (ECT)	29	39.19
Future Caregivers
Caregiver	N	% (Out of 74)*
Parents	41	55.40
Spouse	21	28.37
Friends	5	6.76
Son	4	5.41
Non-blood relative	1	1.35
Brother	7	9.46
Sister	2	2.70
Spouse + parents	8	10.81
Brother + parents	6	8.11
Spouse + son	3	4.05
Sister + parents	5	6.76
Spouse + brother	3	4.05

*Total does not add to 100% as a few patients had given multiple options.

Discussion

Socio-demographics

Our study sample was relatively younger (mean 33.45 ± 10.53 years). In some previous studies, the age ranged from 36.7 to 42 years.^6,8,28,29 In contrast, the study by Gowda et al.,²³ had a mean age of 33.9 years, which is similar to that in our study. Consistent with previous Indian studies^8,23,28 and a British study,²⁹ our sample was predominantly male (67.6%), in contrast to Swanson et al.⁶ finding of a female predominance (60%). Our study sample predominantly represented a rural population (74.3%), a finding consistent with those from other studies.^23,28 In contrast, another Indian study,⁸ was primarily urban. As in other studies,²³ of our patients (86.48%) had a lower socioeconomic status. This reflects the social structure of the Indian setup, as well as the fact that many patients visiting public hospitals in India belong to lower socioeconomic statuses due to financial constraints.

Mental Capacity

In our study, we found that 89.19% of PWMI had intact MC. This rate is higher than the findings of a British study,²⁹ which reported a rate of 42.5%, as well as other studies conducted in India: Kumar et al.,⁸ reported 76.22%, and Grover et al.,¹⁶ reported 25%. Unlike the study by Grover et al.,¹⁶ which used the MacCAT-T to assess MC in inpatients with psychosis, our outpatient group presented a broader range of diagnoses. This variability among diagnoses may help explain why we observed a higher rate of intact MC in our study.

In Owen et al.’s study,³⁰ 60% of inpatients lacked MC to decide on therapy. The rate varied depending on the diagnosis; in individuals with mania, it was 97%; in those with personality disorder, it was 4%. Psychiatric ward patients who were admitted informally frequently had mental incapacity. Under the Mental Health Law, incapacity and incarceration were closely connected, regardless of a person’s capacity. The authors concluded that although mental incapacity to make treatment decisions is widespread among patients admitted to psychiatric units, it cannot be presumed. The scenario was typical for those confined under the Mental Health Act and common for people who were admitted voluntarily.

Forty-seven point three percent of our sample was receiving treatment for schizophrenia. Previous studies by Swanson et al.,⁶ had 59% of patients who had schizophrenia and psychotic illness, while in an Indian study,⁸ all the patients had schizophrenia or other psychotic illness. Ninety-five percent of our patients with bipolar affective disorder (BPAD) had intact MC. Owen et al.,²⁹ found that the BPAD manic episode had the strongest association with MC, and drug and alcohol use was associated with retaining capacity. We also had similar findings, with all the persons with alcohol and benzodiazepine dependence syndrome (100%) having intact MC. Eighty percent of our persons with schizophrenia, and all persons with depressive disorder (100%), had intact MC (Table 2).

In contrast, few other investigations found that MC was impaired in inpatients with psychosis and BPAD.^29–31 These variations across different studies could be due to regional, ethnic, and sociocultural factors, as well as methodological issues. While we used the CAGD, a few other Indian studies,¹⁶ and the British study,²⁹ used the MacCAT-T.

Insight and Mental Capacity

Table 3 shows that the insight is statistically significantly associated with a history of psychiatric illness (p < .05) and socioeconomic status (p < .01). Our ITAQ analysis revealed a strong correlation (p < .001) between treatment-focused decision-making and higher insight scores (mean score 15.04 ± 5.48). This suggests that higher insight is associated with better MC and a more favorable patient attitude toward treatment. This finding is similar to the British study,²⁹ on patients with psychotic disorders, BPAD, and non-psychotic disorders, where low insight was associated with impaired MC, and impaired insight was significantly linked with mental incapacity in persons psychotic disorders and BPADs than in the non-psychotic disorder. Thus, insight was highly predictive of MC in the former diagnostic group. This suggests that when determining MC, assessing insight is crucial. Our results support the relationship between insight and MC as observed by Owen and others.¹⁶ This emphasizes the need for a closer look at whether laws about capacity can effectively support the autonomy of patients who have different levels of insight.

Advance Directive

According to the MHCA, “every person, who is not a minor, shall have a right to make an AD in writing, specifying any, or all of the following, namely: (a) The way the person wishes to be cared for and treated for a mental illness; (b) the way the person wishes not to be cared for and treated for a mental illness; (c) the individual or individuals, in order of precedence, he wants to appoint as his NR as provided under section 14.” The “type of family” the patient belongs to is related to the patient’s choice of caregiver and NR for future illness. 89.18% of our patients belonged to the nuclear family, which is in line with Philip et al. (85%).²⁸ On BADI, 55.40% of our patients chose their parents as NR. The majority of Indian PWMI feel at ease designating an NR, typically a family member, to exercise their decision on their behalf when they are unable to do so.¹⁰ This may be attributed to the closer proximity of family members and culturally ingrained practices regarding decision-making.

Forty-seven point two nine percent of our PWMI chose to be treated on an inpatient basis in the future, and 53.70% refused future admissions. In another Indian study,³² 15% of patients refused future hospitalization, 22% refused the use of chemical restraints in the future, and 62% refused the use of physical restraints in the future. Thirty-nine point one nine percent of our sample agreed to future ECT, in contrast to Tekkalaki et al.,³² who reported that 47% of their patients refused future ECT. Patients gave various reasons for choosing not to take any treatment in the future, such as “there is no need for future treatment as they are now cured,” “mental illnesses are self-limiting,” “because of stressful events,” “medications have side effects,” and others. However, patients predominantly choosing to be treated by psychiatrists could be a reflection of Indian patients’ trust in the doctors, which is a welcome finding.

Philip et al.,²⁸ used Education-cum-Assessment Tool to help patients formulate their AD; it took around 14.6 minutes to develop AD in patients who had MC. We found that both MC and AD can be assessed in just 15 minutes using CAGD and BADI. It contradicts earlier studies,¹⁵ which asserted that assessing ADs requires significant facilitation. This implies that efficiency and patient autonomy can be achieved even in resource-limited settings, such as India. Our results demonstrate strong patient preferences for psychiatrist-led care and parental involvement, despite Cochrane’s meta-analysis,¹¹ indicating insufficient evidence for the utility of ADs. This highlights a uniquely Indian context of reliance and family dependence in psychiatric planning. Many studies have emphasized the importance of AD. A randomized trial,³³ found that 90% of the PWMI could choose AD. In the study by Kumar et al.,⁸ 65% of patients completed their AD without assistance, 29% required prompts, and 6% required assistance from a healthcare professional.

In contrast, Philip et al.,²⁸ reported that 2% of PWMI were able to make the AD independently, while 98% required assistance. The findings of Gowda et al.,²³ and Tekkalaki et al.,³² are consistent with our AD response rate of 83.79%, confirming that there is cultural preparedness for directive-based planning. However, the example from Philip et al.,²⁸ shows that different situations require different types of support. This highlights the importance of creating tailored intervention strategies.

The MC and AD of the PWMI play a crucial role in treatment options and modalities. A systematic review,³⁴ concluded that MC evaluation is possible; most PWMI have MC and can make decisions on treatment. The PWMI should be educated about the need for and utility of AD; they also need to be aware of various treatment methods, their advantages, and disadvantages, to make a well-informed and proper decision about AD. It should also be noted that the insight correlates with the MC; thus, PWMI with impaired MC may not be in a position to give valid AD. Even otherwise, the mere presence of MC or insight may not always lead to acceptable ADs; ethical and psychological factors require additional consideration. Hence, appropriate safeguards should be used to ascertain the MC of PWMI before writing an AD; also, without understanding the concept, an AD may be written off by the PWMI.³⁵ Therefore, the assessment of AD should be done when the person has recovered from illness or has better insight or MC. For PWMI who lack the MC for admission, the MHCA 2017 provides an alternative legislative framework of “supported admission.”

Challenges to MC evaluation should be identified, and efforts to overcome them through training and capacity-building programs,¹⁸ should be implemented nationwide.

Strengths

This study focuses on an essential but often overlooked issue in Indian psychiatry: Evaluating MC and assisted decision-making (AD) for PWMI. It provides current data that aligns with the latest laws and goals for mental health services in India. We used reliable tools to collect data that fit the local context. To meet regulations, we assessed MC using the Central Mental Health Authority’s CAGD, which the Government of India accepts for assessing MC in PWMI. This is one of the few published studies to demonstrate its utility. India’s MHCA 2017 promotes the use of culturally appropriate measures, such as the CAGD, which our study utilizes to address this contextual gap. We chose the CAGD because it aligns with local practices and follows the recommendations of the MHCA, 2017. This approach shifts from using global standards to using evaluation methods that are more relevant to India, unlike the MacCAT-T used in earlier Indian studies.¹⁶ We also strengthened our methodology by using the BADI and ITAQ, which are recognized in both Indian and international research. A structured approach to ADs and a clear operational definition of MC aligned with the MHCA 2017 benefits the study. This alignment with the law makes the findings more relevant and valuable for treatment. Combining legal, clinical, and ethical aspects in a single research project can significantly enhance studies on mental health policy and psychiatric practice.

This study looks at a wide range of mental illnesses, not just schizophrenia or bipolar disorder, like some past Indian research. This broader focus makes the findings more relevant and valuable in outpatient psychiatric settings. When creating a collaborative, rights-based approach to care, mental health professionals can gain valuable insights into how patients choose between outpatient care and psychiatrist-led treatment. They should also pay attention to the critical link between the insight and MC of PWMI. This study contributes to the growing body of research showing that it is possible to evaluate MC and assist ADs in standard psychiatric practice, particularly in busy outpatient settings. The use of government-approved tools highlights their effectiveness, and since the assessments take only about 15 minutes to complete, they can be easily integrated into routine care.

Limitations

We excluded persons with personality disorders, dementia, delirium, and more severely ill or agitated persons; also, the sample constituted a treatment-seeking population presenting to the tertiary care public urban psychiatric hospital. The sample did not include other mental illnesses, such as anxiety disorders; being a tertiary care public psychiatric hospital, primarily, persons with severe mental illnesses present for treatment. Hence, the results may not be generalizable to other mental illnesses, community-dwelling individuals, and those visiting GHPUs, private, and non-urban MHEs. As this was a descriptive exploratory study, we did not have a prespecified hypothesis, and no sample size calculation was performed. Being a cross-sectional study, causal relationships could not be established. The MC is dynamic,³⁶ and may alter over time. A PWMI might not have MC at one point but regain it later; therefore, MC evaluations should be an ongoing process tailored to the specific decision. As this was a non-blinded study, interviewer bias could have inadvertently crept in. We did not establish inter-rater reliability for the interviewers. The CAGD is based on a subjective clinical assessment and gives an impression of MC as either “lacking” or “present.” Unlike MacCAT-T, it does not provide a clear metric for determining MC. This could lead to subjective bias. Hence, there is a need to develop an objective, standardized assessment tool, such as the MacCAT-T, for the Indian population that can provide a quantitative component.

Conclusions

In this study, the majority of PWMI had MC and were able to give AD for managing their mental illness. The MC was closely related to insight. Understanding and documenting MC and AD are crucial for effective management. Controlled, methodologically sound studies across various mental illnesses and MHEs, with larger samples, are the need of the hour. There is a dire need to develop and standardize a metric-based MC assessment instrument for the Indian population.

Supplemental Material

Supplemental material for this article is available online and includes the completed STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement.³⁷

Footnotes

Acknowledgements

We thank Dr Srinivasa SRR Yerramilli, Professor and Head, Department of Psychiatry, KMC, Warangal, Telangana, India, for his valuable comments and proofreading of the manuscript.

The authors thank Ms Gauri Soni, PGP in data science, Hyderabad, India, for help with statistical analysis.

Authors’ Note

Rajshekhar Bipeta serves as the Editor-in-Chief and is the author of this manuscript. As a result, the editorial responsibilities were assigned to Ravi Teja Innamuri, the Associate Editor. Rajshekhar Bipeta did not participate in the peer review process or any editorial decision-making related to this manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

The authors utilized the Grammarly tool for grammatical proofreading of the article, and assume full responsibility for the entire content of the manuscript, including the parts reviewed and edited by Grammarly.

Declaration Regarding any Prior Publication of the Work and Presentation

Oral presentation at ANCIPS, Kolkata, India, on 29 January 2020.

Ethics Approval

The study started after obtaining approval of the Institutional Ethics Committee, Osmania Medical College, Hyderabad, and was conducted in accordance with the Declaration of Helsinki. Approval No: ECR/312/Inst/AP/2013/RR-19; Date: 8 May 2019.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Informed Consent

Written informed consent was obtained from the participants and their legally authorized representatives for participation in the study.

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