Insight and decisional capacity in schizophrenia: Public policy implications

Deborah Reed (2001)

This dissertation develops public policy recommendations regarding the problem of impaired insight in schizophrenia and related deficits in decisional capacity. In brief, impaired insight is defined as general lack of awareness of having a mental disorder, of the likely effects of the disorder, and of the need for treatment. Deficits in insight and thus in decision-making ability often have major consequences. These can include treatment non-compliance, relapse, deterioration of quality of life, homelessness, violence and criminalization. Such consequences affect mentally ill individuals, their families and friends, as well as society at large. Providing humane and appropriate treatment for mental illness, expanding knowledge and developing more effective treatments through research, and taking steps to prevent violence, homelessness and criminalization of the mentally ill constitute matters of public policy. These policy concerns must straddle a delicate ethical balance: safeguarding individual autonomy and respecting individual rights, while providing adequate protections to those who are impaired and to the public. This project reviews the current state of knowledge regarding impaired insight in schizophrenia and describes what is known about its relationship to decision-making capacity. The dissertation focuses mainly on treatment decision making, but relevant research and criminal justice decision-making issues are noted as well. Formalized decision-making practices in these areas are presented and applicable legal and ethical principles are reviewed. Present-day policy is critiqued, areas of needed improvement identified, and specific recommendations developed for policy modification, research and services that might be provided by professional psychologists.