Mental capacity, insight, and severity of illness in psychiatric in-patients: A prospective study

Capacity is a dynamic, task-specific, time-specific clinical construct that may be impaired either temporarily or permanently due to the medical or psychiatric illness, necessitating varying degrees of support from caregivers. There is paucity of Indian prospective studies focusing on the mental capacity, insight, and severity of illness (SOI) in psychiatric in-patients.

The current study aimed to prospectively examine the capacity, insight, and SOI in psychiatric in-patients in a tertiary level psychiatric center.

A prospective observational study design was used to assess patient's capacity for making mental healthcare and treatment decisions, insight and SOI using the guidance document, clinical grading of insight and brief psychiatric rating scale (BPRS), respectively. In-patients aged 18 years and above, any gender and any psychiatric diagnosis as per ICD-11 diagnostic criteria were included, and intellectual developmental disorder was excluded. All assessments were conducted at the time of admission (baseline) and repeated every week until discharge.

Of 233 in-patients studied, 75% (n = 175) had incapacity and 80% (n = 187) had absent insight at the baseline. Incapacity at baseline was noted in those with delirium, catatonia, BPRS >31 (88%), absent insight (92.6%), and psychotic symptoms (94%). Only 6.42% (n = 12) of cases with the absent insight at baseline had preserved capacity. On repeated measures analysis, those with substance use disorders (SUDs; ≤1 week) and mood disorders regained capacity earlier (1-3 weeks) than psychotic disorders (>3 weeks; P < 0.001).

Insight appears to be the best discriminator for capacity status for psychotic disorders, bipolar disorders, and SUDs. Presence of delirium, catatonia, and intoxication reflect obvious lack of capacity; while absent insight, BPRS >31, psychotic and bipolar disorders suggest significant association with incapacity. Effective treatment improves capacity and insight earlier in persons with SUDs and bipolar disorders than psychotic disorders.