The neuropsychological basis of competence to consent in first-episode schizophrenia: A pilot metacognitive study

Background: This study was designed to explore the neuropsychological basis of competence to consent to treatment in first-episode schizophrenia by evaluating its differential and joint links with cognitive versus metacognitive performance. Methods: Twenty-one first-episode patients were assessed with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and a metacognitive version of the Wisconsin Card Sorting Test (WCST). In addition to the standard administration of the WCST, subjects were also asked to rate their level of confidence in the correctness of each sort (prior to getting the feedback) and to choose whether they wanted each sort to be "counted" toward their overall performance score on the test. Each "ventured" sort received a bonus of 10 cents if correct but an equal penalty if wrong. Results: Compromised capacity to consent was more strongly related to deficits at the metacognitive level than to cognitive deficits per se. Moreover, prediction of competence to consent significantly improved when adding the new, free-choice metacognitive measures to the conventional WCST measures but not the other way around. Conclusions: These preliminary results suggest that metacognition plays a fundamental role in capacity to consent, which might be at least equally important for decision-making competence as cognitive deficits per se.