Is she able to make informed decisions about the risks and benefits of treatment choices for her depression including no treatment?

That is the heart of the question! Does her expression of refusal of treatment represent a truly informed decision? She is clearly verbalizing a choice, however it's unclear whether she has all of the relevant information needed to make that decision and if she has the capacity to reason such a decision through. In the four competence model of capacity, a person is deemed to have capacity if she can: (1) communicate a clear choice without vacillating significantly, (2) demonstrate a factual understanding of the medical issues at hand, including the risks and benefits of the treatment and any reasonable alternatives, (3) comprehend the situation as it applies to her and the consequences of her decisions, demonstrating insight into her illness and need for treatment, and (4) display logical thought process in the course of coming to her decision.

What if she wants to consent to treatment but lacks capacity? Would you not prescribe her an antidepressant?

I would prescribe an antidepressant and use a flexible sliding scale approach to capacity assessment. Patients are generally allowed to consent to treatment as long they can communicate a choice. Capacity is typically only called into question when a patient refuses the proposed treatment. Patients opposing treatment are routinely held to higher standard of capacity as they run the risk of physical harm, going against the right to treatment, and the ethical principal of beneficence. Taking an antidepressant medication is a low-risk, high-benefit intervention, and so I would employ a relatively low standard for assessing her capacity, and would accept her consent. By requiring only such a minimal level of capacity, the patient's autonomy as well as her physical well-being, are protected.

I'm not sure what you want to discuss, unless you begin to go through the four competence model and give possible answers everything is theoretical. It would be foolish to waste time guessing possibilities until you've learned more information. She might be a famous researcher in depression studies or she may think the hospital is trying to poison her.

Without more information this is just an exercise in how to determine capacity. What would be more interesting is if you gave us some possible scenarios. What are the tricky answers that patients give? How much decision making is guided by the "you'll thank me later" treatment philosophy in psychiatry. The idea that we know what is best and afterwards the patient will be grateful we did what we thought was right. I am not denigrating this philosophy, I've employed it at times, all psychiatrists have.

Seth, and everyone else in this discussion, how far would you go with the "you'll thank me later" philosophy? Take for example if this case developed in the following way:

The patient's daughter (previously unknown) calls you and asks that you prescribe liquid fluoxetine which the home health aide would surreptitiously slip into the patient's food. The daughter hopes that this intervention would help her mother's depression and recently increasing irritability. What would you do then?

Another interesting twist is one that I have encountered before. At what point does one say patient cannot make decision or they are making bad decisions and that emergency guardianship may be warranted. This happens fairly regularly in a medical setting, especially in the elderly.

In response to your question Abigail, I am assuming that this pt is stil her own guardian. As such, we would need permission to talk to her daughter unless there is an overriding concern for safety. Even if the idea suggested by the daughter is good, I may not be able to give it as the pt may refuse. If that is the case, I would ask for a quick meeting with the pt, the daughter and perhaps social service to discuss reasoning and alternatives.

In my state, the legal requirement for emergency certification and involuntary medication is that a patient has to have a mental disability, and, as a result of this disability, the patient's unsupervised presence is likely to cause a substantial risk to self or others. Unfortunately, without a guardian, we see lots of family appeals for care in such cases, but the law ties our hands.

So far, Mrs. E does not show much recognition of her illness, and any of benefits of treatment. She therefore lacks the capacity to direct her health care, esp psychiatric care.

The first thing to do is to educate her and also acknowledge her life-long preferences. Uness her depression is severe enough (description does not support much intensity to her depression), treatment should begin with establishment of a rapport.

If Mrs. E is compromised in minimum safety or self care due to psychological symptoms, she needs to be treated more aggressively: hospitalization and a second opinion should be sought without losing much time.

Unless I know the caretakers adequately, I hesitate to be party to giving medications under disguise.

I always find it disturbing when any decision is made by a patient (particularly if they're older) which differs from the doctors, their competence is brought into question. There was no question of Mrs E's competence before this incident.
I'd like to see Mrs E's doctor sitting down and having a nice long discussion with her to find out what she wants out of life at this time.
Even though the best "medical decision"for Mrs E may be to go on antidepressants, Mrs E is more than a clinical case study; she is a woman who has 80 years of life experience and a life plan of her own. Perhaps, Mrs E has made a logical decision that fits in with her plan for her life and perhaps we should respect that.
Whatever her situation or diagnosis, our first responsibility should be to ascertain what she wants and see if we can accommodate that. "I'm 80 years old and I'm not about to start taking medications now. That would kill me!" sounds like the sort of response I'd expect from a lot of older people - do we deem all older people incompetent?
Try reading the description above replacing "Mrs E" with "I" and assessing it from a human as well as clinical viewpoint; perhaps your decisions will be different.

Ron Fletcher (RN1 & Mental Health Nurse)

Obviously there are legal issues to consider - e.g. slipping the liquid fluoxetine into her food/drink could have legal consequences. But this matter also speaks to paternalism - when can a benevolent health care-worker decide for a patient?

This vignette is too bare-bones to have a meaningful discussion about ethical issues involved. For example, issues to be considered in this case begin with - what is the underlying diagnosis resulting in the presenting symptoms? The above presentation could be seen in depression, but could also be seen in progressive dementia, or in an infectious process (e.g., UTI) in a person with dementia, or thyroid dysfunction, and so on. Even if it is 'just' depression, in this vignette, Mrs. E is not refusing treatment for depression - she is just refusing antidepressant medications. We don't know if there has been a frank and open discussion about other treatment alternatives and their relative potential advantages and disadvantages. Even if this is depression, does she have a h/o recurrent depression? Historically, how does her depression behave? When it progresses, does she often become suicidal? Does she often stop behaving the way she is now? Too many unanswered questions to have a meaningful discussion about ethics

Does the patient understand the consequences of refusing treatment? People can refuse therapy and medication but if they understand the consequences and that the person is refusing based on his/her values and not the clinical depression, it would be difficult in a nonthreatening situation i.e suicidal or homicidal thoughts, plan and/or intent, to start involuntary treatment. Is this patient meeting her biological needs ie. sleeping, eating that does not put her at medical risk for dehydration. Does she understand that eating and sleeping "less than usual"is a sign of depression? What would her response be if an MD told her that she was at medical risk and "failure to thrive"?

Hi, I'm a practicing Psychiatrist & psychotherapist from India.
Case of Mrs. E seems interesting, though information is not adequate, it seems that she is suffering from Dementia with depressive features. However she needs full medical evaluation to arrive at full clinical diagnosis. She may accept to get evaluated. Clinician's rapport would do needful.
Secondly, she is not denying for treatment. It seems that she needs to talk her concern out, that she fears that medicine might kill her due to fragility as a result of ageing. If clinician can persuade her with brief psycho therapy, establish good working rapport, she might give consent willingly for treatment. If therapist add little Gestalt therapy along with cognitive therapy if needed, her consent to treatment wound not be a difficult task.
If she satisfies criteria of competency then this psychotherapy is inevitable. But suppose she does not satisfies all 4 criteria then she can be treated under consent obtained from authentic career or legally permissible person.
If all these avenues fail then only covert medication can be resorted at. Documentation of all record becomes mandatory in case of covert medication. I support covert medication fully under all documentary formalities in some of the rare cases as a last resort. I value life more than Autonomy or person's right to deny treatment, etc.
Dr. Madhav Raje, 16.04.12