Factors associated with decision-making capacity in persons with mental illnesses: Baseline findings of a prospective...

Decision-making capacity (DMC) is central to informed consent and patient autonomy in psychiatric practice. While impaired DMC is common among inpatients, the relative contributions of insight, severity of illness (SoI), and socio-demographic factors remain less explored, particularly in the low- and middle-income countries.

To identify the socio-demographic and clinical correlates of DMC among psychiatric inpatients at the time of admission.

Psychiatric inpatients (N = 233) were assessed at the time of admission for DMC using the guidance document. Data on socio-demographic characteristics, family psychiatric history, duration of illness, psychiatric diagnosis as per ICD-11 diagnostic criteria, SoI using brief psychiatric rating scale (BPRS), and clinical grading of insight were recorded. Logistic regression, receiver operating characteristic (ROC), and precision-recall curve (PRC) analyses was used to identify baseline correlates of DMC.

Family history of psychiatric illness, being single, absent clinical insight and higher SoI (BPRS > 31) showed significant association with incapacity at baseline. In multivariable models, higher grades of clinical insight alone showed 85-times more likelihood for preserved DMC; and upon including SoI into the model-lower BPRS scores ≤31 showed 33-times more likelihood to have preserved DMC, while higher grades of insight further increased the likelihood to 139-fold, after adjusting for other variables. Overall, insight and SoI accounted for 91% of the variance, with an overall classification accuracy of 97.4%. ROC and PRC analysis identified an insight grade ≥2 as the optimal cut-off, with 87.3% precision, 94.8% sensitivity (recall), and 95.4% specificity.

Clinical insight (≥2) is the strongest correlate of preserved DMC in psychiatric inpatients, with SoI (BPRS ≤ 31) providing an additional influence, at baseline. Routine context-specific structured assessments of insight and SoI should be integrated into psychiatric evaluations for DMC to improve objectivity, and support patient autonomy.