Review of the Outcomes of the Consent and Capacity Board in Patients with Schizophrenia Spectrum Illness

Mental health legislation allows involuntary treatment under certain circumstances. It also permits patients to appeal and receive an independent review. ¹ Review boards aim to provide a balance between medicolegal considerations, while protecting patients’ rights and ensuring the public’s safety. ²

There is little known about the consent and capacity board (CCB) decisions on findings of incapacity, involuntary admissions, or community treatment orders (CTOs). This study examines the outcomes of CCB hearings in patients with schizophrenia, who have a higher rate of involuntary admissions, ³ incapacity for treatment, ⁴ and issuance of CTOs. ⁵

Methods

This was a retrospective chart review of all the CCB hearings held in our Schizophrenia Program, from December 2014 to December 2017, for involuntary admission, incapacity for treatment, or issuance/renewal of a CTO.

Results

A total of 122 hearings were held during the study period. The mean age of the participants was 39.7 years, and 72% were male. A total of 58.7% of CTOs and 18.8% of involuntary admissions were mandatory reviews. About 95% of participants were incapable of making treatment decisions.

An overturned decision was made in 5.35% of involuntary admissions and 4.76% of CTO hearings. None of the hearings overturned the finding of incapacity for treatment.

Reasons for decisions were available for 83.3% of hearings with an overturned outcome. Of the available reasons, 80% of revocations were due to a technicality in the process of issuing a CTO or an involuntary commitment. Of the 6 patients with overturned outcomes, 2 were lost to follow-up, 3 discontinued treatment, and 1 committed an assault upon leaving the hospital. Only 1 patient continued treatment during the 3-month follow-up period.

Discussion

This study is the first to look at the outcome of hearings for a finding of incapacity and issuance/renewal of a CTO. Available literature on the CTO focuses on effectiveness and impact on treatment outcomes but does not examine the hearings held for CTOs. ^{6 –9} As such, there is no comparison available for these findings. Moss and Redelmier ¹⁰ reported 18% revocation of involuntary admissions by tribunals across all psychiatric diagnoses. Our lower rate is likely due to the difference in patient population.

Of the available reasons, 80% of rescissions were due to technical deficiencies in the process of issuance of a CTO or an involuntary commitment. While compliance with the technical aspect of the process is important, overturning such decisions solely based on a technicality puts patients at risk of experiencing additional morbidity. Furthermore, no culpability exists with the review boards, putting physicians at risk of liability when adverse outcomes occur as a result of such decisions.

About 60% of the tribunals for CTOs were mandatory reviews. Our result suggests a need for reassessment of the frequency of mandatory hearings, considering such hearings are reported as barriers to issue CTOs, ¹¹ the low rate of rescissions by tribunals, and the associated cost of holding hearings.

The limitations include inherent methodological restraints in retrospective studies. Because of the low number of overturned decisions, this study was not powered enough to assess the impact of potential variables, including incapacity, on hearing outcomes.

Naista Zhand, MD University of Ottawa, Ottawa, Ontario, Canada [e-mail] David G. Attwood, MD, FRCPC Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada Schizophrenia Program, Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada