Evidence-Based Reviews

Assessing decisional capacity in patients with substance use disorders

Current Psychiatry. 2019 October;18(10):35-40

References

1. Karlawish K. Assessment of decision-making capacity in adults. UpToDate. https://www.uptodate.com/contents/assessment-of-decision-making-capacity-in-adults. Updated July 2019. Accessed August 19, 2019.
2. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007. HCUP Statistical Brief #92. https://www.ncbi.nlm.nih.gov/books/NBK52659/pdf/Bookshelf_NBK52659.pdf. Published July 2010. Accessed August 19, 2019.
3. Smothers BA, Yahr HT. Alcohol use disorder and illicit drug use in admissions to general hospitals in the United States. Am J Addict. 2005;14(3):256-267.
4. Jeste DV, Saks E. Decisional capacity in mental illness and substance use disorders: empirical database and policy implications. Behav Sci Law. 2006;24(4):607-628.
5. Bechara A, Damasio H. Decision-making and addiction (part I): impaired activation of somatic states in substance dependent individuals when pondering decisions with negative future consequences. Neuropsychologia. 2002;40(10):1675-1689.
6. Grant S, Contoreggi C, London ED. Drug abusers show impaired performance in a laboratory test of decision making. Neuropsychologia. 2000;38(8):1180-1187.
7. MacDonald TK, Zanna MP, Fong GT. Decision making in altered states: effects of alcohol on attitudes toward drinking and driving. J Pers Soc Psychol. 1995;68(6):973-985.
8. Boettger S, Bergman M, Jenewein J, et al. Assessment of decisional capacity: prevalence of medical illness and psychiatric comorbidities. Palliat Support Care. 2015;13(5):1275-1281.
9. Charland LC. Chapter 6: Decision-making capacity and responsibility in addiction. In: Poland J, Graham G. Addiction and responsibility. Cambridge, MA: MIT Press Scholarship Online; 2011:139-158.
10. Martel ML, Klein LR, Miner JR, et al. A brief assessment of capacity to consent instrument in acutely intoxicated emergency department patients. Am J Emerg Med. 2018;36(1):18-23.
11. MacLullich AM, Beaglehole A, Hall RJ, et al. Delirium and long-term cognitive impairment. Int Rev Psychiatry. 2009;21(1):30-42.
12. Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316.
13. Rehm J, Hasan OSM, Black SE, et al. Alcohol use and dementia: a systematic scoping review. Alzheimers Res Ther. 2019;11(1):1.
14. Jain A, Christopher P, Appelbaum PS. Civil commitment for opioid and other substance use disorders: does it work? Psychiatr Serv. 2018;69(4):374-376.
15. Grisso T, Appelbaum PS. Chapter 6: Using the MacArthur competence assessment tool – treatment. In: Grisso T, Appelbaum PS. Assessing competence to consent to treatment: a guide for physicians and other health professionals. New York, NY: Oxford University Press; 1998:101-126.
16. Hazelton LD, Sterns GL, Chisholm T. Decision-making capacity and alcohol abuse: clinical and ethical considerations in personal care choices. Gen Hosp Psychiatry. 2003;25(2):130-135.

Bechara and Damasio⁵ found that the decision-making impairment seen in some patients with SUDs was similar to that observed in patients who have lesions of the ventromedial prefrontal cortex. In both groups of patients, the impaired decision-making was characterized by a preference to opt for high immediate reward despite even higher future losses.

These deficits were also observed by Grant et al.⁶ In this study, patients with SUDs displayed markedly impaired performance on the Gambling Task, which examines decisions that result in long-term losses that exceed short-term gains. However, patients with SUDs performed similarly to controls on the Wisconsin Card Sorting Test, which evaluates the ability to form abstract concepts and to shift from established response sets.

MacDonald et al⁷ used a laboratory experiment and 2 field studies to test the hypothesis that alcohol affects attitudes and intentions toward drinking and driving. Their findings support the concept that alcohol intoxication decreases cognitive capacity such that people are more likely to attend to only the most salient cues.⁷

Whether the impairment documented in such studies is a contributing factor in addiction or is a result of addiction remains uncertain. While individuals with SUDs may have some level of impairment in decision-making in general, particularly in regard to their substance use, their decisional capacity on specific clinical decisions should be assessed carefully. In a study of 300 consecutive psychiatric consultations for decisional capacity at an urban hospital, Boettger et al⁸ found that 41% were related to SUDs. Of these, 37% were found to have impaired decisional capacity.

Impaired decision-making in patients with SUDs may specifically pertain to choices related to their addiction, including⁹:

consent for addiction treatment
consistency in maintaining a choice of recovery
changing values regarding treatment over time
capacity to participate in addiction research involving the use of addictive substances.

Continue to: It is important to recognize...

Assessing decisional capacity in patients with substance use disorders

References

Pages

Recommended Reading